Male with Chronic Obstructive Pulmonary Disease
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Case 1 | ||
| Chief Complaint (CC) |
A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents to the clinic with a cough he has had for the past 2 weeks. | ||
| Subjective | denies chest pain, denies night sweats, admits to having a fever but does not know the temp. | ||
| VS | (BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air. | ||
| General | patient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs | ||
| HEENT | EYES: no injection, no increase in lacrimation or purulent drainage; EARS: normal TM: Normal NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Obstructed air passages |
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| Respiratory | lung crackles in LLL, no wheezes or rhonchi noted; does not clear with coughing; dullness to percussion over the LLL; shallow respirations and is 30, accessory muscles use not present | ||
| Neck/Throat | no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline |
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| Heart | Regular rate and rhythm, no murmur, S3, or S4 | ||
Once you received your case number, answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
Submission Instructions:
- Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
|
|
Case 1 | ||
| Chief Complaint (CC) |
A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents to the clinic with a cough he has had for the past 2 weeks. | ||
| Subjective | denies chest pain, denies night sweats, admits to having a fever but does not know the temp. | ||
| VS | (BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air. | ||
| General | patient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs | ||
| HEENT | EYES: no injection, no increase in lacrimation or purulent drainage; EARS: normal TM: Normal NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Obstructed air passages |
||
| Respiratory | lung crackles in LLL, no wheezes or rhonchi noted; does not clear with coughing; dullness to percussion over the LLL; shallow respirations and is 30, accessory muscles use not present | ||
| Neck/Throat | no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline |
||
| Heart | Regular rate and rhythm, no murmur, S3, or S4 | ||
Once you received your case number, answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
Submission Instructions:
- Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
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