Reference no: EM133324465

Francis Coulter Age 32 years Opening Scenario Francis Coulter is a 32-year-old male here for an episodic visit with a complaint of head congestion. He has been seen in your practice for the past two years. History of Present Illness "I have had a cough and runny nose for over two weeks. About a week ago I developed a headache and started blowing thick, yellow-green mucus out of my nose. Bending over seems to make the headache worse. Acetaminophen improves the headache but doesn't take it away. I've also been using pseudoephedrine 30 mg, two tablets every 12 hours with little relief." The patient denies tooth pain or pain with mastication. Medical History Seen here for a physical examination one year ago with no positive findings. No history of surgery, hospitalizations, coronary artery disease, hypertension, or diabetes. Social History Nonsmoker, rare alcohol (less than three drinks a month). Works as a junior high school science teacher. Medications Pseudoephedrine hydrochloride: 60 mg every 12 hours for the past three days Cough drops for sore throat Acetaminophen: 1000 mg every four hours as needed for headache Allergies NKDA 22 Review of Systems HEENT: Mild pain with swallowing; denies ear pain

Questions:

Chief complain?

History of present illness?

Review of systems?

Physical examination Findings?

Please identify three differential diagnoses and provide rationales for each diagnosis.

Please provide the most appropriate diagnosis for this case and the rationale for the diagnosis chosen.

Does the patient require any referral to any other medical team member for further evaluation and management?