case study 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.
Objective Data
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
for this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your case study number has been assigned since the first day. Continue to use the same case study number assigned.
Answer the below questions. Note that all your responses should apply to your specific patient from your assigned case study.
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 each differential diagnosis.
Submission Instructions:
You have been assigned your case number (See Announcement), and you will post about the case number you have been assigned.
You will reply to your peers that have posted on the other two case studies (One of each).
Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 2 academic sources other than your textbook
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