Question 3666

Question Answered step-by-step AS is a 44 year old male being seen for a cough and fever HPI “I… AS is a 44 year old male being seen for a cough and fever HPI”I have been sick for about a week. I feel like I have been running a low-grade fever, but when I took my temperature 2 days ago, it was just a little over 100 F.  I have been coughing up some reddish brown sputum, but not all that much. I cough fairly frequently, but I did not have any cough medicine in the house. I really hope you can help because I haven’t felt this sick in a while. I feel like I’ve been run over by a truck. I’ve had bronchitis a few times before but never this bad. I had a TB test about 4 years ago and it was negative.” He denies sweats and chill, he notes a decreased appetite but is still able to eat and drink. He denies shortness of breath but does feel more winded lately. His wife gave him some Sudafed he has been taking for the last 3 days with no improvement in symptoms. No know exposures to TB or COVD, but works as a police officer in NYC. Had Pfizer COVID vaccine #1 & #2 four months ago, when his symptoms began he got a rapid and PCR COVID test at work (on day 3 of symptoms) and they were both negative.  Family History:MGM died 82 breast CA; MGF died 77 MI; PGM died 80 complication of DM-2; PGF died 77 CVAMother: 81 A&WFather: died 80 CVANo siblingsSon: 22 A&W Social History:Works as police sergeant in NYC. Married with one grown son who is at graduate school. Smoke 1 ½ PPD X 26 years. Alcohol: few beers on the weekends, never on work nights; rarely more than 2-3 beers in an evening.  Medications:Vitamin A & CSudafed 2 pills 3 times a day for 3 days ROS:General: Usually good, not great last few days, lower stamina than normal last few daysSkin: no itching or rashesHEENT: No history of head injury; no corrective lenses, denies eye pain, excessive tearing, blurring or changes in vision; no tinnitus or vertigo, denies frequent colds, hay fever or sinus problems.Neck: no lumps or painRespiratory: Usually has no shortness of breath, no nocturnal dyspneaCardiac: No chest painAbdomen/GI: No nausea, vomiting, constipation or diarrhea; denies belching, bloating and dark or light colored stool.GU: No dysuria or difficulty starting urine stream; denies any problems getting or maintaining and erection.Extremities: Mild joint pain with significant activityNeuro: No headaches or dizzinessEndocrine: No polyuria, polyphagia, polydipsiaCirculatory: No excessive bruising or bleeding. PE VS: T: 98.7, P 86 RR 18 BP 162/82Ht: 5′ 10″ Wt 172 (BMI 24.7)General: Well developed, well nourished; no acute distress; appears stated ageHEENT: Normocephalic, PERRLA; EOM intact; fundi normal; nares patent and non injected; throat without redness or lesionsNeck: Supple without adenopathy or thyromegalyRespiratory: Coarse breath sounds scattered bilaterally, does not change with cough; no wheezes or crackles; symmetrical resonant percussionCardiac: Regular rate and rhythm, no murmurs appreciated Abd: Soft and non-tender, no hepatosplenomegaly; bowel sounds normoactive Provide your differential diagnosisFull problem list, the cases may have multiple problems. Tests or labs to be orderedPlan of care including follow up care for all problems Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

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