Friday, September 17, 2010

You! Diagnose Me!


Demographics
This is the case of a 23 yo male, medical student, Roman Catholic by religious affiliation, single by civil status. Reliability is 100%.

Chief Complaint
Nasal Congestion for 3 days duration.

History of Present Illness
3 days prior to consult, patient experienced recurrent bouts of allergic rhinitis characterized by increased watery mucosal discharge over both nares. Associated signs and symptoms include bilateral itchiness over external nasal ala and congestion of both nares. Patient did not take any medications. Signs and symptoms were alleviated by rest and increased fluid intake; aggravated by cigarette smoking.

2 days prior to consult, patient started to feel feverish and easy fatigability. No exact temperature recorded. All signs and symptoms persisted and got worse. Patient took Cetrizine oral, Phenylephrine oral, Paracetamol oral to alleviate allergic rhinitis, nasal congestion, and fever respectively. Patient took all medications twice a day after meals. Cetirizine and Phenylephrine mildly alleviated signs and symptoms. Paracetamol lowered patient’s temperature to normal. Patient did not seek consult.

1 day prior to consult, patient’s condition persisted. Associated symptoms now include unproductive cough. Patient started on Clindamycin 300 mg three times a day. Persistence of signs and symptoms prompted patient to seek consult.

Diagnosis?
Differentials?

Here's my bet: URTI. :p

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