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Assignment: Week 5 Case Study Diagnosis for the Patient Essay

Assignment: Week 5 Case Study Diagnosis for the Patient Essay


Primary Diagnosis

Infectious bronchitis is the primary diagnosis for the patient. The condition begins with acute symptoms of bronchitis identified as mild wheezing, low-grade fever as well as rhonchi (Tanner & Roddis, 2018). These manifestations are identified in the patient in addition to the complications of malaise, occasional nausea and myalgia. The condition is likely to be precipitated by an influenza infection. From the patient’s chest x-ray (CXR), there is thickening along the pleural lining suggesting infection in the chest cavity. However, in the analysis of the CXR, the patient does not have an enlarged heart. Besides, a gastric bubble is identified on the left side beneath the diaphragm confirming an infection. We can, therefore, rule out a heart condition although several tests on the heart can be requested to ensure accuracy in the diagnosis.

Differential Diagnosis

The patient is likely to have influenza (Flu). The symptoms of the latter are associated with fever, fatigue and body aches. In the case study, Flu is a viral infection that is potential in causing infectious bronchitis (Moustafa et al., 2014). From the examination of the CXR, the patient’s chest indicate an infection which can be attributed to the invasion by the influenza virus.

The case study manifest symptoms of community-acquired pneumonia (CAP). This is indicated by complaints of fever, general body weakness and a productive cough (Ewig, 2014). The condition is a bacterial infection and affects the lungs. This can be identified by the thickening of the pleural lining as observed in the patient’s chest x-ray.

In the case study, the patient is likely to common cold. This is evident by symptoms such as fever, myalgias and cough. The condition can be spread from individuals infected to those without the infection and is mainly transmitted through air (Moustafa, Lewallen & Feldman, 2014). Since the client works as a law clerk, he is likely to contract the condition due to increased contacts with people.

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Role of Patient History and Physical Exam on Diagnosis

As per the case, it is essential for physicians and nurses to determine a working diagnosis within the shortest time possible.

Assignment Week 5 Case Study Diagnosis for the Patient Essay

Assignment Week 5 Case Study Diagnosis for the Patient Essay

Through patient history and physical exam, clinicians gain more information about the patient. Often, most patients present to the care facilities with multiple complaints and it would be important to listen to what they say before requesting for medical examinations (Buttaro et al., 2017). Besides, the key to patients’ diagnosis depends on the history of their medical complaint and physical exams refines the history to provide objective data used for developing an accurate diagnosis. Patient history is vital for selective diagnostic testing and in this case, it saves time as the findings are used to design diagnostic study on the complications of the patient.


For the infectious bronchitis, administer Tessalon Perles PO 100mg three times daily and this is mainly for controlling coughs. Give the patient Ibuprofen 600mg PO 6 hours PRN together with Acetaminophen 650mg PO every 4 hours PRN (Tanner & Roddis, 2018). Administer Zofran ODT 4mg PO every 6 hours for the management of nausea. A health education against tobacco smoking is also provided to the patient as this aggravates the condition.

In the case of Influenza, administer Tamiflu 75mg PO Daily x 10 days. Monitor the progress of the patient and instruct him to adhere to the prescribed medication regimen (Papadakis, McPhee & Rabow, 2019). Advise the patient to seek further medical attention if symptoms persist or in case of development of new infections (Moustafa et al., 2014).

The community-acquired pneumonia is treated by providing Levofloxacin 750mg PO q24h. This is administered in a combination with amoxicillin-clavulanate 2g PO q12h and azithromycin 500mg PO once followed by 250mg on the second day PO 1 daily for 4 days (Papadakis, McPhee & Rabow, 2019). Instruct the patient to avoid alcohol intake as this affects the metabolism of the prescribed medication (Ewig, 2014). Advise the patient to avoid crowded places and ensure adequate ventilation in the house or office to avoid transmission of the infection.

For common colds, administer acetaminophen 1g PO every 6 hours relieve fever and pain associated with the condition. Provide dextromethorphan 30mg PO every 6 hours to manage cough (Moustafa, Lewallen & Feldman, 2014). Inhaled irritants from tobacco aggravates treatment process and therefore the client should be instructed to avoid smoking of tobacco.

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