[49F] Experiencing respiratory and systemic symptoms
Patient Description
A 49-year-old female presents with symptoms starting yesterday, including a mild intermittent cough producing thick mucus, a constant throbbing and aching headache rated at 6/10 in severity, fever, body aches, and chest congestion. The headache is described as being all over the head, affecting the temples and sinus area, and is alleviated by laying down. The patient has a medical history of hypertension and diabetes, diagnosed last year, and is currently taking Ozempic and Losartan. There are no known allergies or adverse reactions to medications, and no other medications have been reported. The patient has not identified any specific activities that exacerbate the cough.
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Arora's Assessment
Cough, body aches, headache, fever, and chest congestion
Differential diagnosis
- Given the symptoms, the most likely diagnosis is an upper respiratory tract infection (J06.9). Other possibilities include influenza (J10.1), pneumonia (J18.9), and COVID-19 (U07.1).
- Less likely but possible given the symptoms are sinusitis (J32.9), bronchitis (J20.9), and allergic rhinitis (J30.9).
Plan
Order a rapid influenza test and a COVID-19 test given the current pandemic. Recommend rest, hydration, and over-the-counter pain relievers for symptom management. If the patient's symptoms worsen or do not improve within a week, consider prescribing antibiotics to treat a possible bacterial infection.
Headache
Differential diagnosis
- Given the patient's history and presentation, the most likely causes of the headache are tension headache (G44.2), sinus headache (R51), and migraine (G43.9).
- Less likely but possible given the symptoms are cluster headache (G44.0) and medication overuse headache (G44.41).
Plan
Recommend over-the-counter pain relievers for headache management. If the headache persists or worsens, consider prescribing a stronger pain reliever or a preventive medication. If the patient's headaches continue to be a problem, consider referring her to a neurologist for further evaluation and treatment.
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1 yr ago
