Level 2: Cough – Contrasting Case #2: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 33 year old man presenting to the urgent care clinic with a 2-day cough and fever. He is clearly sick, but is in no acute distress. He notes that he awoke yesterday morning feeling feverish, chilled, lethargic, and having a deep, painful cough. He states that his cough is productive for 4-5 tablespoons of thick, yellow sputum. He denies experiencing any hemoptysis. Nothing seems to make the cough better or worse. He says that he had been “feeling achy” about 2 days ago, but otherwise was not experiencing symptoms at that time. He decided to wait one day to see if the symptoms would get better, but states that he woke up this morning “feeling even worse.” He reports feeling mildly short of breath and experiences mild pleuritic discomfort on his left side. His temperature this morning when he awoke was 101.5. He states that a couple of his co-workers have missed work for similar symptoms this week.

PMH: None

FMH: Father, Mother and sister alive and well

SH: Patient works at the local high school as a math teacher and football coach. He lives with his wife and two daughters. He reports only “having a couple of beers” once a month. He states that he occasionally chews tobacco during football practice, but denies ever smoking cigarettes.

General: No recent unintended weight loss.

HEENT: Reports having a headache off and on during the last several days. No rhinorrhea, otorrhea or otalgia. No epistaxis.

Cardiovascular: No palpitations or edema.

Respiratory: See HPI.

Musculoskeletal: Reports diffuse, bilateral arthralgia for the past several days

Physical Examination –
VS: Height 6’2’’, Weight 230lbs, BMI 29.5 HR 60, BP 124/88, RR 20, Temperature 102.1

General Appearance: Patient clearly appears sick and coughs frequently.

HEENT: Normocephalic, atraumatic, PERRLA, examination of nasopharynx and oropharynx is unremarkable with no erythema or exudates.

Cardiac: Normal S1, S2 present with no rubs, gallops, or murmurs.

Lungs: Dullness to percussion at left lower lung base with resonance in all other lung fields. Auscultation reveals inspiratory crackles at left lower lung field with bronchial breath sounds. Auscultation of all other lung fields contain vesicular breath sounds with no adventitious sounds present.