Denies nausea vomiting or abdominal pain Denies history of seasonal allergies

Denies nausea vomiting or abdominal pain denies

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Denies nausea, vomiting, or abdominal pain. Denies history of seasonal allergies. She does not drink or smoke. She is currently taking Lisinopril 20 mg daily for hypertension and Xanax 0.5 mg PRN. No significant family or social history to note.
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Pertinent PE Patient is alert and oriented. She is in no apparent distress. Vital signs: Vital signs: BP 136/72, HR 68, RR 19, Temp 98.9, sats 100% on room air Upon physical examination, patient was noted to have mild rhinorrhea with clear discharge. Otherwise, pink and moist turbinates were present. Tonsils +1. Mild erythema noted in posterior pharynx. Positive post nasal drip. No pain or tenderness noted upon sinus palpation. Lung sounds were clear to auscultation. No wheezing or adventitious sounds noted. No enlargements or tenderness noted in the lymph nodes. NARROW Based on the H&P key findings, identify an appropriate differential. Upper respiratory infection Acute bronchitis Pneumonia ANALYZE Analyze the differential by comparing and contrasting the possibilities. Use pertinent positive and negative findings to argue for or against each diagnosis in your differential. Rank your diagnoses in order of most likely to least likely.
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At this point, my differential diagnosis list (ranked from most likely to least likely) includes: URI, acute bronchitis, and pneumonia For URI, positive pertinent findings include rhinorrhea, nasal congestion, sore throat, cough, mild erythema in the posterior pharynx, mild fatigue, and normal assessment findings on chest auscultation. Pertinent negative findings include lack of phlegm, sneezing, or laryngitis. However, the list of common symptoms of an URI does not necessarily apply to every case.
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  • Spring '19
  • Common cold, nasal congestion

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