SOLVED71

42 year old male, John A., complains of “aching in the chest” from coughing. He said he has had the cough for a little over a week now and it is not getting any better. He has tried OTC Robitussin Cough with minimal relief. He says that the cough started as a dry cough, but now has some yellow productive sputum. John said that he has cut down his smoking considerable because of the coughing. He says, “I thought this was a cold at first, but when the cough started and got worse, I became concerned.” He says that the night time is the worst for the cough and when he wakes he sometimes has some dark sputum. He says he has a fever on and off with some sweating, fatigue, and SOB on exertion. General: Denies any weight loss, appetite is less than normal because of the cough, Patient reports that he does have a fever of 99-100 F sporadically with some fatigue. Chest: Chest wall “ache” secondary to the cough. Lungs: Patient complains of anterior wall chest “ache” from frequent coughing. SOB with exertion. Denies any wheezes, stridor, hemoptysis, or night sweats. Reports a productive cough that produces dark sputum in the morning otherwise is yellow. Pt has hx of URI and Bronchitis in the past, last episode was 2 years ago. CV: Denies any chest pains, radiating pain to the arms or neck. Denies any palpitations or syncopal episodes. Denies any claudication, varicose veins. Denies any hx of CV disease. GI: Patient has a hx of GERD and uses PPI to control. Denies any dysphagia, abdominal pain, nausea, vomiting, hematemesis. Denies any diarrhea, constipation, blood in stool, hemorrhoids or changes in bowel pattern. • Based on the information given, what are the systems you would include in the Objective portion for exam and why? O: PE VS T 99.0 F, RR 20, HR 102, BP 140/88, SpO2 93%, Ht. 72″ Wt. 195# BMI 26 General: WDWN, appropriately dressed, appearing good hygiene, denies any weight gain or weight loss, appetite is less than his usual. Chest: Chest wall is tender to anterior palpation of the chest wall. There is no supraclavicular lymph nodes appreciated. Lungs: AP diameter is 2:1, respirations are tachypneic, lungs have decreased breath sounds with course breath sounds in the bases to auscultation anterior and posteriorly. Percussion is dull over the lower lobes bilaterally. Positive bronchophony and whispered pectoquilery, anteriorly and posteriorly in the lower lobes bilaterally. CV: S1 and S2 are intact, heart rate is tachycardic, no rubs or murmurs appreciated. GI: There is no distention on inspection of the abdomen. No scars or lesion. Bowel sounds are present in all four quadrants by auscultation, Percussion is tympanic in all areas. Liver boarder is percussed to 6cm boarder, liver is not palpable. There is no abdominal tenderness to palpation in all areas. There is no tenderness in the epigastrium to palpation. 1. What are the significant findings on physical exam? 2. Based on the subjective and objective data, what are your differential diagnosis (include your top 4 differential diagnosis and order them)?
SCIENCE
HEALTH SCIENCE
NURSING

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