Throat, Respiratory & Cardiovascular Disorders
Case 1 Chief ComplaintCC)
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), 02 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: normalTM: NormalNOSE: 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, accessorymuscles 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 S4post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic source
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic examination do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.