[54M] With severe cough and sinus symptoms

Patient Description

A 54-year-old male presents with a 7-day history of a severe productive cough that worsens when lying down and is accompanied by green and blood-tinged mucus. The patient has experienced a fever and reports a swollen tongue, possibly due to biting during coughing, which has not occurred previously. He describes a sharp headache localized to the temples and sides, which is alleviated by caffeine; this is a new symptom for the patient. Additionally, he reports head congestion and pain behind the eyes. The patient has a medical history of diabetes diagnosed 1 year ago and coronary artery disease diagnosed 6 years ago. He is currently taking Lisinopril, Crestor, Metformin, Farxiga, Tadalafil, and Vitamin D3. Known allergies include Penicillin and most antibiotics. The patient does not smoke and has no family history of respiratory diseases.

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Arora's Assessment

What might be happening

Based on the information you have provided, possible diagnoses include:

  • Acute Sinusitis: This condition is characterized by inflammation of the sinuses, often due to an infection. Symptoms can include a headache, facial pain, cough, and nasal congestion. Green or yellow mucus is also common.

    • Treatment usually involves rest, hydration, and over-the-counter remedies. If symptoms persist or worsen, antibiotics may be prescribed.
  • Bronchitis: This is an inflammation of the bronchial tubes, the airways that carry air to your lungs. It often follows a cold or other respiratory infection. Symptoms can include a cough with mucus (sputum), which can be clear, white, yellowish-gray or green in color — rarely, it can be streaked with blood.

    • Treatment for bronchitis typically involves rest, fluids, and over-the-counter cough remedies. If your bronchitis is caused by a bacterial infection, your doctor may prescribe antibiotics.
  • Pneumonia: This is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing.

    • Treatment for pneumonia involves antibiotics, rest, fluids, and over-the-counter remedies to manage symptoms.

Please note that these are possible diagnoses and you should consult with a healthcare professional for an accurate diagnosis.

What you can do

You should seek immediate medical attention given your symptoms and medical history. Here are some steps you can take:

  1. Contact your healthcare provider: Given your symptoms and medical history, it's important to get a professional evaluation as soon as possible.

  2. Rest and hydrate: Make sure to get plenty of rest and stay hydrated. This can help your body fight off infection and recover.

  3. Over-the-counter remedies: Over-the-counter cough suppressants and pain relievers may help manage your symptoms. However, these should not replace a consultation with a healthcare provider.

What you should look out for

If you experience any of the following symptoms, seek immediate medical attention:

  • Difficulty breathing or shortness of breath
  • Chest pain
  • Confusion or changes in mental function
  • Blood in your sputum
  • High fever

Remember, while I strive to provide accurate information, I'm not a doctor and this advice should not replace a consultation with a healthcare professional.

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1 yr ago

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People Also Ask


What are the common symptoms of acute sinusitis?

Common symptoms of acute sinusitis include headache, facial pain, nasal congestion, cough, and green or yellow mucus. It often follows a cold or respiratory infection.


How can bronchitis be distinguished from pneumonia?

Bronchitis typically involves a cough with mucus and may follow a cold, while pneumonia is more severe, with symptoms like high fever, chills, and difficulty breathing. A healthcare provider can perform tests to distinguish between the two.


What are the potential side effects of the medications the patient is taking?

Potential side effects of Lisinopril include dizziness and cough; Crestor may cause muscle pain; Metformin can lead to gastrointestinal issues; Farxiga might cause urinary tract infections; Tadalafil can cause headaches; and Vitamin D3 is generally well-tolerated but can cause high calcium levels if overdosed.


What should I do if I have a productive cough with blood-tinged mucus?

If you have a productive cough with blood-tinged mucus, it's important to seek medical attention to rule out serious conditions like pneumonia or other infections. A healthcare provider can offer a proper diagnosis and treatment plan.


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