History of Present Illness (HPI)
The patient is a 49-year-old female who presents with a 4-day history of cough, congestion, body aches, and feeling alternately hot and cold. She initially reported improvement but experienced worsening symptoms on Friday evening, with the production of green sputum. The patient has a history of hypertension, managed with lisinopril, but missed her medication on the day of presentation due to forgetting to take it in the morning.
Differential Diagnosis
- Single Most Likely Diagnosis
- Acute Bronchitis: The patient's symptoms of cough, congestion, body aches, and production of green sputum are consistent with acute bronchitis, a common respiratory infection.
- Other Likely Diagnoses
- Acute Sinusitis: The patient's symptoms of congestion and production of green sputum could also be indicative of acute sinusitis, an infection of the paranasal sinuses.
- Influenza: The patient's symptoms of body aches, feeling alternately hot and cold, and cough could be consistent with influenza, a viral respiratory infection.
- Exacerbation of Hypertension: The patient's elevated blood pressure and history of hypertension, combined with her missed medication, could contribute to her symptoms.
- Do Not Miss Diagnoses
- Pneumonia: Although less likely, pneumonia is a potentially life-threatening condition that could present with similar symptoms, such as cough, congestion, and production of green sputum.
- Pulmonary Embolism: A pulmonary embolism could present with sudden onset of cough, chest pain, and shortness of breath, and is a potentially life-threatening condition that should not be missed.
- Rare Diagnoses
- Tuberculosis: Although rare, tuberculosis could present with chronic cough, weight loss, and night sweats, and should be considered in patients with persistent or worsening symptoms.
- Bronchiectasis: A rare condition characterized by permanent dilation of the bronchi, bronchiectasis could present with chronic cough, production of purulent sputum, and recurrent respiratory infections.