HPI: Greg Brazier, a 30 year old

HPI: Greg Brazier, a 30 year old male presents, to the clinic with a 3 week history of mildly productive hacking cough. He reports the following: feeling “wheezy” getting over a “winter cold” a few weeks prior to this episode fatigue and intermittent fever coughing so much his chest hurts a mild sore throat and nasal congestion denies recent travel denies sick contacts Greg has no history of lung disease. PMH: Positive recurrent childhood tonsillitis. PSH: Tonsillectomy MEDS: Mucinex D BID; No other medications, vitamins, or supplements. SOCIAL Hx: Single farmer, lives alone in rural Illinois. He has never smoked or used other forms of tobacco. He drinks an occasional beer. ROS: General: Denies unplanned weight loss. HEENT: See HPI. Denies headache, facial pain, otalgia, tinnitus, or vision changes. RESP: See HPI. Denies shortness of breath or pain with inspiration. CV: Denies chest pain, palpitations, or peripheral edema. GI: Denies heartburn, nausea, vomiting, diarrhea, or abdominal pain. PHYSICAL EXAM: Temp 99.6 F Pulse 96 bpm BP 128/82 mm Hg Resp 22 shallow Oxygen Saturation 97% room air HEENT Exam: No oropharyngeal erythema or uvular deviation. Nares are mildly erythematous with gray boggy turbinates. No maxillary or frontal sinus tenderness. No anterior or posterior cervical lymphadenopathy. RESP: Vesicular breath sounds with scattered mild coarseness and occasional faint wheezing. CV: RRR, S1, S2, No gallop, rub, or murmur. Questions? What are some of your differential diagnoses in this case? What other information would you seek from this patient? What tests or diagnostic tools would you consider in this case, if any?

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