Chief Complaint: Cough
History of Present Illness
A 59 year old female presents to the urgent care clinic complaining of a 24-hour history of fever and chills, with an episode of rigors last night. She is complaining of a productive cough and increased dyspnea. She reports she does have a baseline “smoker’s cough.” She reports having to use her inhaler constantly since yesterday. Denies any chest pain at rest but does report mild discomfort when coughing. The patient does report that her grandson had a fever and cough a few weeks ago but it only lasted a few days and resolved on its own.
Past Medical History
COPD
Diabetes
Current Meds
Combination steroid/long-acting beta agonist inhaler
Metformin
Social History
2 pack/day smoker with lifetime pack year history of 60 years
Family History:
Father, HTN and Lung Cancer
Mother, Diabetes
Sister, Diabetes
Review of Symptoms
As per HPI, not completed
Physical Examination
Vital signs; T 101.3, BP 168/95, RR 28, HR 116, O2 94% on RA
General: Well developed, alert and oriented, pt speaks in full sentences
HEENT: Ears clear, mucous membranes dry, no erythema to nasal turbinates or oropharynx, no lymphadenoathy
Heart: Regular rhythm, rate tachycardic
Lungs: + for tactile fremitus, expiratory wheezes and rhonchi present
MSK: Moves all extremities, pulses intact, no edema
Skin: Warm and moist
Case Study Discussion – Part I:
Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.
What further history, further examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions?
1. pneumonia
infection would be bacterial, viral or fungal.in this condition, lungs become inflamed and air sacs and alveoli filled up with fluid.
symptoms
patient symptoms
she had a history of smoking and medical history of COPD increases the risk for pneumonia.
diagnostic method to clarify :
2.Tuberculosis
symptoms
patient symptoms
diagnosis
she has 60 years history of smoking.
3.Acute bronchitis
It is the inflammation of trachea and bronchi.
symptoms
patient symptoms
diagnosis
Chief Complaint: Cough History of Present Illness A 59 year old female presents to the urgent care clinic complaining of...
Chief Complaint: History of Present Illness A 52 y.o. female presents with the chief complaint that her tongue is red x 2 weeks. Her dental hygienist mentioned it to her at a recent apt and told her to get it “checked out.” States she has noticed a change in taste when she eats spicy foods. She reports that she noticed the change in taste when she started using a new brand of toothpaste one month ago. Past Medical History/Current Meds...
Chief Complaint: Facial weakness History of Present Illness A 38 year-old female presents to the emergency department stating that over the past 36 hours, she has developed right sided facial weakness (Links to an external site.)Links to an external site. and drooping, an associated right sided ear and jaw ache and inability to close her right eye. She is unable to move both the upper and lower side of her face. She does report a history of an upper respiratory...
Chief Complaint: Nausea & Vomiting History of Present Illness A 24-year-old woman presents to your urgent care clinic complaining of nausea and vomiting for the past 4 weeks. She had no prior gastrointestinal problems until the onset of symptoms 4 weeks ago. She generally develops nausea about 1/2 hour after eating and then vomits non-bloody material about an hour later. Solid food causes more symptoms than liquids, and the amount of food needed to cause symptoms has been decreasing. Otherwise,...
Week 3 Case Study Chief Complaint: Facial weakness History of Present Illness A 38 year-old female presents to the emergency department stating that over the past 36 hours, she has developed right sided facial weakness (Links to an external site.)Links to an external site. and drooping, an associated right sided ear and jaw ache and inability to close her right eye. She is unable to move both the upper and lower side of her face. She does report a history...
Chief Complaint: Knee Pain History of Present Illness A 59 y.o. male in town for a conference comes to the urgent clinic with severe right knee pain. His knee was fine yesterday when he played nine holes of golf. He describes a history of osteoarthritis in both knees for which he takes celecoxib. Also, about a month earlier, he got an injection in his right knee that resulted in decreased pain and asks if another knee injection would help. This...
Chief Complaint: Facial Pain History of Present Illness: A 40 y.o. female comes to the clinic for a recheck following a 10-day course of antibiotics for sinusitis. She states that the fever has dissipated, but she continues to have pressure and stuffiness over the right eye. Her mucus is thick yellow, but she has no green or bloody mucous. HA is relieved by Tylenol or Advil. She has been using nasal spray and decongestants with minimal relief. She denies ST,...
Chief Complaint: Rash History of Present Illness A 24 y.o. male presents for a pre-employment physical and mentions a rash on his chest. He noticed the rash last night and says it is “very itchy.” He has not noticed any other skin changes. Overall, he feels well without any accompanying symptoms. He is a teacher and spent most of last weekend doing yard work. Past Medical History Allergic rhinitis Denies surgeries or serious illnesses/hospitalizations Current Meds Allegra OTC Family History...
Week 4 Case Study 66 unread replies.66 replies. Chief Complaint: Rash History of Present Illness A 24 y.o. male presents for a pre-employment physical and mentions a rash on his chest. He noticed the rash last night and says it is “very itchy.” He has not noticed any other skin changes. Overall, he feels well without any accompanying symptoms. He is a teacher and spent most of last weekend doing yard work. Past Medical History Allergic rhinitis Denies surgeries or...
Chief Complaint: Weakness History of Present Illness A 68 y.o. male comes to the office complaining of fatigue and weakness, which started approximately 1 month ago. Initially, the patient thought he might have a virus, but he became concerned when the symptoms persisted. He sleeps 9 hours at night and takes one to two 1-hour naps each day. He states he just can’t stay awake and reports his sleep is restorative. He has noticed mild general weakness, which is non-focal....
Case Study: A 12-year-old girl who presents to the walk-in clinic complaining of shortness of breath and dry cough that has been present for 3 weeks. It is worse at nighttime and with activity. When she plays soccer with her friends, she often feels tight in the chest after a few minutes of play. On further questioning, the patient admits to occasional episodes of shortness of breath and coughing over the last 2-3 years, but never this severe. These episodes...