Reference no: EM133268238
Assignment - HPI: Sherry, a 42 year old female receptionist presents to the clinic with a 2-day history of sudden onset fever, headache, sore throat, malaise, nasal congestion, body aches, and dizziness. She reports a hacking non-productive cough. She denies recent travel. She denies sick contacts. She has no history of lung disease.
PMH: Hypertension
PSH: Total Knee Replacement (R), Total Hysterectomy
MEDS: Lisinopril 10mg PO QD; MVI; Tylenol 650mg PO BID;
SOCIAL Hx: Married, lives with spouse. She does not smoke or use tobacco products. She does drink wine with dinner nightly.
ROS:
General: Denies unplanned weight loss.
HEENT: See HPI.
RESP: See HPI. Denies shortness of breath or pain with inspiration.
CV: Denies chest pain, palpitations, or peripheral edema.
GI: Denies heartburn, nausea, vomiting, diarrhea, or abdominal pain.
PHYSICAL EXAM:
Temp 101.3 F Pulse 117 bpm BP 132/80 mm Hg Resp 22 Oxygen Saturation 95% room air
HEENT Exam: Face is flushed. No oropharyngeal erythema or uvular deviation. Nares are patent and moist without erythema. No maxillary or frontal sinus tenderness. No anterior or posterior cervical lymphadenopathy.
RESP: Vesicular breath sounds with scattered mild coarseness and occasional faint wheezing. Cough is hacking and non-productive.
CV: RRR, S1, S2, No gallop, rub, or murmur.
What are some of your differential diagnoses in this case?
What other information would you seek from this patient?
What tests or diagnostic tools would you consider in this case, if any?
What is your final diagnosis?
What treatment and follow-up plan would you recommend in this case?
What patient education would you provide this patient?