Patient Information:
R. J.
50 years old
Male
White
S .
CC: nasal congestion
HPI: The patient is a 50-year-old white male who developed an itchy nose, eyes, palate, and ears five days ago. The pain began three days ago and is described as “tolerable” and is rated at three out of ten in terms of intensity according to the visual analog scale and numeric rating scale described by Bendinger & Plunkett (2016). The pain is located in the throat, above the larynx, and it is pulsating in nature. The pain is usually aggravated by a cough or sneeze before subsiding to the “tolerable” nature. The patient reports an eight out of ten-pain intensity when either coughing or sneezing. The patient tried an expectorant (Mucinex) two days ago with minimal relief of his symptoms. The patient reports not to have any allergies he is aware of but has minor intolerances to Sulphur based drugs, which make his eyes jaundiced with no other accompanying symptom.
PMHx: the patient has no prior surgeries and only reports of one serious flu case that rendered him hospitalized for five days about 10 years ago. The patient’s immunization status is up to date, and his last tetanus jab was in the summer of 2013.
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SHx: the patient works at a construction site as a manager who oversees other personnel working in the site and allocates duties based on each employee’s skills. The patient reports the availability of hazard masks at his worksite, which he always uses. As for hobbies, the patient occasionally indulges in leisure site seeing adventures during his free time. His latest adventure was in Honolulu, Hawaii, about two months ago, and he was accompanied by his wife. The mother died at 85 of uncontrolled hypertension, and the father is known diabetic but has had controlled sugars for the past 4 years. The patient has two younger sisters, all who are well with no chronic disease priors. The patient reports no current use of tobacco or alcohol but notes moderate use of alcohol during his campus life when he was in his early 20s, after which he stopped. The patient also lives in the suburbs of Minneapolis in a small gated community setting.
ROS:
GENERAL: No weight loss, moderate fever, no weakness, or fatigue.
HEENT: Eyes: No visual loss, no blurred vision, no double vision, slightly watery. ENT: No hearing loss, presence of occasional sneezes and coughs, presence of congestion, runny nose, and inflamed throat with slight pains.
SKIN: No rash or itching
CARDIOVASCULAR: No chest pain or discomfort. No palpitations or edema.
RESPIRATORY: the presence of shortness of breath, cough, and sputum.
NEUROLOGICAL: No headache, no dizziness, no paralysis. No change in bladder or bowel control.
HEMATOLOGIC: No anemia, bleeding, or visible bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma or eczema.
O.
VS: BP 118/86mmHg; P 92; R 21; T 100.5; Wt: 186 lbs.; Ht: 72”
General- the patient appears restless and anxious.
Gastrointestinal- the abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas. No masses or splenomegaly are noted.
Pulmonary- lungs are clear
ENT- throat is inflamed and erythematous. Tonsils are normal in size. The nasal cavity is pale and boggy with clear thin secretions. Presence of enlarged nasal turbinates.
Diagnostic results:
Skin prick test: Eguiluz-Gracia et al. (2019) report that the presence of wheal, a red mosquito bite-like bump in the skin, is indicative of allergic rhinitis which has similar symptoms to the ones provided by the patient.
TB blood test: The CDC (2018) notes that this test may be administered to a patient at risk of contracting the disease and has received the BCG vaccine. The patient immunization is up to date, hence making this test the best alternative for him.
Rapid diagnostic test for influenza: Vemula et al. (2016) point out the symptoms of influenza, which range from those the patient gave to others that appear in advanced stages of the disease. The authors note the use of the rapid diagnostic test to diagnose influenza in human beings.
Full hemogram: the white blood cells and differential counts are useful in the diagnosis of a respiratory infection. Patients often report a decreased lymphocyte count (Chen et al., 2020).
A.
Differential Diagnosis:
Common cold: based on the patient’s symptoms, the diagnosis depends mostly on the clinical symptoms provided by the patient and observed by the clinician. According to Mosler & Unger (2019), the symptoms of common cold depend majorly on the duration of the infection. They can vary from slight coughs to full-blown chest congestion and coryza. With this in mind, common cold is the primary diagnosis before the other lab tests ascertain otherwise.
Allergic rhinitis: Eguiluz-Gracia et al. (2019) report that patients with allergic rhinitis exhibit similar symptoms to those of common cold or influenza, hence recommend the use of the skin prick test to differentiate between the three conditions.
Tuberculosis: TB is a common condition that is highly communicable especially, among the elderly population, more so, in people who are often in crowded places. Most TB cases are only diagnosed when it is too late, and symptoms have already worsened. It is, therefore, important to test for this illness in a suspected case (CDC, 2018).
Influenza: Vemula et al. (2016) report that influenza is a common seasonal epidemic that affects the American population each year. The signs of influenza and common cold are intertwined, and, in some cases, patients can be misdiagnosed if the appropriate lab tests are not requested. With this in mind, it is essential to confirm the presence of the virus and provide the patient with the appropriate treatment.
Upper respiratory tract infection: just like influenza, URTIs have similar symptoms to common cold. In many cases, both URTIs and common cold occur together, and this makes it hard to decipher between the two. Chen et al. (2020) report that a full hemogram showing the lymphocyte counts is useful in the diagnosis of URTI.
References
Bendinger, T., & Plunkett, N. (2016). Measurement in pain medicine. Bja Education , 16 (9), 310- 315.
Centers for Disease Control and Prevention (CDC). (2018, December 12). Testing for TB Infection . https://www.cdc.gov/tb/topic/testing/tbtesttypes.htm
Chen, Z. M., Fu, J. F., Shu, Q., Chen, Y. H., Hua, C. Z., Li, F. B., ... & Wang, Y. S. (2020). Diagnosis and treatment recommendations for pediatric respiratory infection caused by the 2019 novel coronavirus. World Journal of Pediatrics , 1-7.
Eguiluz-Gracia, I., Pérez-Sánchez, N., Bogas, G., Campo, P., & Rondón, C. (2019). How to Diagnose and Treat Local Allergic Rhinitis: A Challenge for Clinicians. Journal of clinical medicine , 8 (7), 1062.
Mosler, F., & Unger, S. (2019). Measuring guideline adherence for the diagnosis and management of common cold and pneumonia in rural Gambia. A case for a Clinical Decision Support System in rural sub-Saharan Africa? European Respiratory Journal, 54 (63), 727.
Vemula, S. V., Zhao, J., Liu, J., Wang, X., Biswas, S., & Hewlett, I. (2016). Current approaches for diagnosis of influenza virus infections in humans. Viruses , 8 (4), 96.
