Level 2: Cough – Contrasting Case #3: 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 male presenting to the clinic with a 3-day cough and facial pain. He is clearly sick, but is in no acute distress. He describes the cough as a dry, “hacking” cough. Patient states that the cough occasionally brings up 1-2 teaspoons of white sputum. He states that nothing seems to make it better or worse and “it’s just been constant for the past 3 days”. Mr. Drone also states that during this time he has been experiencing facial pain on both sides of his face in a maxillary distribution that radiates down to his teeth. He also states that sometimes he experiences the pain in his temples. Mr. Drone states the pain is a 7/10, sharp pain that is typically worsens when he bends over. Patient states that the pain has been the same for the past 3 days and that he decided to be evaluated because he is “tired of feeling bad”. Patient states that about 1 week prior to these symptoms he had been experiencing rhinorrhea, sneezing, and malaise. Denies any recent sick contacts.

PMH: None

FMH: Father, Mother and sister all alive and well

SH: Patient works at the local high school as a math teacher and football coach. He lives with his wife and 2 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.

HEENT: Reports having a headache off and on during the last several days. Also states that he has been experiencing “severe” rhinorrhea for the past week.

Cardiovascular: No palpitations, chest pain, or edema.

Respiratory: No dyspnea, hemoptysis, or pleuritic pain.

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 100.1

General Appearance: Patient clearly appears sick and coughs frequently.

HEENT: Normocephalic, atraumatic, PERRLA, Both tympanic membranes are able to be visualized and are unremarkable. Skin overlying maxillary sinuses show mild erythema and the maxillary sinuses are tender to palpation. Frontal sinuses are non-tender bilaterally. Nasopharynx shows erythematous turbinates bilaterally with a fair amount of purulent discharge present in each nostril. Oropharynx is unremarkable with pink, moist mucosa. Uvula is midline with mild erythema, but no exudate present.

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

Lungs: Auscultation of all lung fields contain vesicular breath sounds with no adventitious sounds present.