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
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’s presenting symptoms.
5. Give rationales for each differential diagnosis.
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