What is your primary working diagnosis

Reference no: EM133590993

Question: S/ Mr. M (40 y/o) presents for 8 days of sinus congestion, sore throat, fatigue, and dry cough. He states he had a fever initially but it has resolved. He is requesting an antibiotic so he can get back to work. He has taken OTC Nyquil and Dayquil with minimal relief. His last visit to a PCP was 10 years ago and has had no care since then.

PMH: Hypertension, Hypothyroid

Soc: Married. Lives with wife and their dog. Has 2 grown children. Occ: Bank associate Tob: 30 pack year history of cigarettes. ETOH rarely Drug use: None

Exercise: none.

Fam hx: CAD, CVA, Lung cancer, colon cancer

O/ Vitals: T 99.3 BP 170/102 HR 88 RR 22 SPO2 93% BMI 35

PE: NAD. A&Ox3. Heart S1S2 RRR, No MRGs. Lungs with diffuse insp and exp wheezes. Dry cough noted during exam. No JVD. TMs intact/clear with effusion. EAC nonobstructed. Pharynx injected, no exudates. Mild anterior cervical lymphadenopathy. Abdomen soft nontender nor organomegaly, BS+ x4 normoactive. No peripheral edema.

List at least 5 differential diagnoses. Explain each one.
What is your primary working diagnosis? Explain why you chose this
What additional diagnostics (labs, radiology, ect) would you order
What is your treatment plan?
What patient teaching do you include?
What follow up do you order?
What other issues do you need to address with this patient?

Reference no: EM133590993

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