Throat, Respiratory & Cardiovascular Disorders

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.

Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 3 academic sources