[29F] Experiencing respiratory and systemic symptoms

Cough with green phlegm, chest tightness, throat pain, lung pain, and loss of appetite

Differential diagnosis

• Given the symptoms and history of asthma, the most likely diagnosis is an acute exacerbation of asthma (J45.901) possibly due to a respiratory infection such as pneumonia (J18.9) or bronchitis (J20.9).
• Other possibilities include COPD (J44.9), influenza (J11.1), and sinusitis (J32.9).

Plan

Perform a physical exam, including auscultation of the lungs. Order a chest X-ray to rule out pneumonia. If pneumonia is suspected, start empiric antibiotic therapy with a medication that the patient is not allergic to, such as azithromycin. Increase the use of inhalers as needed for symptom control. If symptoms persist or worsen, consider hospital admission for further management.

Headache and lightheadedness

Differential diagnosis

• Most likely causes given the presentation and associated symptoms are tension headache (G44.2), sinus headache (R51), and dehydration (E86.0).
• Less likely but possible causes include migraine (G43.0), anemia (D64.9), and hypertension (I10).

Plan

Encourage hydration and rest. If sinusitis is suspected, treat with appropriate antibiotics along with a decongestant. If headache persists despite these measures, consider further evaluation with neuroimaging.

General malaise and loss of appetite

Differential diagnosis

• Most likely related to the suspected respiratory infection (B97.89).
• Other possibilities include depression (F32.9), anemia (D64.9), and thyroid dysfunction (E03.9).

Plan

Monitor symptoms closely. If symptoms persist after resolution of the respiratory infection, consider further evaluation including a complete blood count, thyroid function tests, and a mental health screening.