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Case 1 |
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Chief Complaint |
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. |
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Subjective |
denies chest pain, denies night sweats, admits to having a fever but does not know the temp. |
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VS |
(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air. |
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General |
patient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs |
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HEENT |
EYES: no injection, no increase in lacrimation or purulent drainage; |
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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 |
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Neck/Throat |
no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; |
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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.
