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:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. 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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