04 Aug Bilateral erythema and edema of turbinates with significant yellow drainage on the right.
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.
Subjectivedenies chest pain, denies night sweats, admits to having a fever but does not know the temp.
Objective Data VS(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air.
Generalpatient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5?3?; weight 175 lbs
HEENTEYES: 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
Respiratorylung 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/Throatno neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
trachea midline
HeartRegular rate and rhythm, no murmur, S3, or S4
Answer the following questions:
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.
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