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Mr. Smith is a 70 year-old white male who presents with a three-day history of fatigue, myalgia, arthralgia, chills and a fever of 102 to 104. He denies sore throat or cough. His appetite has been poor but he is forcing himself to eat a small amount of soup. He has a history of chronic sinusitis and almost always has a yellowish nasal discharge. He denies nausea or vomiting but had a loose stool this morning. He is noticing night sweats with his fever. He lives with his wife who is well, but his granddaughter, who came to visit a few days ago on Halloween, had a cold.
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PAST MEDICAL HISTORY: Hypertension: well controlled Osteoarthritis: stable Chronic Sinusitis: status post two sinus surgeries Barrett's Esophagus: status post esophageal dilatation (1994)
PAST SURGICAL HISTORY: MEDICATIONS: SOCIAL HISTORY: |
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On
exam, patient is alert, appears pale, but is non-toxic in
appearance. He is able to move from the chair to the examining
table with some assistance. Vital
signs show a T=99o, BP=122/72, P=72, RR=16. On HEENT: his eye
exam is normal. Ear: normal tympanic membrane with normal
landmarks and reflexes. Nose: slight congestion; nasal mucosa is
somewhat boggy with a small amount of yellowish discharge.
Throat: normal. Examination of the facial bones was normal with
no tenderness. Neck: supple, with a few small cervical nodes.
Lungs: clear to auscultation and percussion. Cardiac exam:
regular rhythm, normal S1-S2, no murmur or gallop noted.
Abdomen: soft, non-tender, liver and spleen are benign, normal
bowel sounds. There is no CVA tenderness noted. Extremities: no
edema tenderness or cyanosis noted. |
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You
decided that the most likely diagnosis for this patient is viral
illness and advised the patient to rest and take Tylenol as
needed for the fever. He was advised to call you if his symptoms
are not better in a couple of days. Three days later, patient's wife called to report that Mr. Smith is not better and continues to have a temperature of 102 to 104. He had lost 10 pounds in one week because of his anorexia and mild nausea. You advised the patient to be seen the same day. In your office, Mr. Smith reported that he still has the same symptoms of myalgia, arthralgia, fever, chills and anorexia. Since yesterday he has been very fatigued and spends most of the day in bed. He is taking Tylenol alternating with Advil for his fever. Since his last visit he developed a slight cough which is productive of yellowish sputum. He denies vomiting, abdominal pain, or dysuria. He has no back pain or chest pain. He denies exposure to tuberculosis. On exam, he is alert and appears weak, but is in no acute distress. Vital signs are a T= 98.8, BP=110/60, P=85 and a RR=16. His HEENT exam is unremarkable except that his lip is somewhat bluish in color. Neck: supple without masses. Lungs: clear to auscultation. Cardiac exam: regular rhythm, normal S1-S2, no murmur or gallop. Abdomen: soft and non-tender, liver and spleen are benign. Extremities: no edema, tenderness or cyanosis. |
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