Case Study – Part 1
Date of visit: November 20,2019
A 62 year-old Caucasian male presents to the office with persistent cough and recent onset of shortness of breath. Upon further questioning you discover the following subjective information regarding the chief complaint.
History of Present Illness
Onset
6 months
Location
Chest
Duration
Cough is intermittent but frequent, worse in the AM
Characteristics
Productive; whitish-yellow phlegm
Aggravating factors
Activity
Relieving factors
Rest
Treatments
Tried Robitussin DM without relief of symptoms
 
Severity
Unable to walk > 20ft without stopping to catch his breath. Last year at this time he routinely walked 1 mile per day without difficulty
Review of Systems (ROS)
Constitutional
Denies fever, chills, or weight loss 
Ears
Denies otalgia and otorrhea
Nose
Denies rhinorrhea, nasal congestion, sneezing or post nasal drip.
Throat
Denies ST and redness
Neck
Denies lymph node tenderness or swelling
Chest
Describes a persistent productive cough upon wakening for the last 6 months. Color of phlegm is usually white-yellowish. Shortness of breath with activity.
Cardiovascular
Denies chest pain and lower extremity edema
History
Medications
Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamin daily
PMH
Primary hypertension
PSH
Cholecystectomy, appendectomy
Allergies
Penicillin (hives)
Social
Married, 3 children
Senior accountant at a risk management firm
Habits
Former smoker (20 pack-year), quit “cold turkey†when father died; Denies alcohol or illicit drug use.
FH
Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker)
Mother is alive (osteoporosis)
Healthy siblings
Physical exam reveals the following:
Physical Exam
Constitutional
Adult male in NAD, alert and oriented, able to speak in full sentences
VS
Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA
Head
Normocephalic
Ears
Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.
Nose
Nares patent. Nasal turbinates clear without redness or edema. Nasal drainage is clear.
Throat
Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.
Neck
Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. No JVD
Cardiopulmonary
Heart S1 and S2 with no murmurs, noted. Lungs clear to auscultation bilaterally with faint forced expiratory wheezes in bilateral bases. Respirations unlabored. Legs without edema.
Abdomen
Soft, non-tender. No organomegaly
Requirements/Questions:
Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. May use approved medical abbreviations. Avoid redundancy and irrelevant information.
Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement (2-3 sentences) of pathophysiology for each.
Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
Rank the differential in order of most likely to least likely.
Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based practice (EBP) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBP evidence.
DISCUSSION CONTENT
Category
Points
%
Description
Application of Course Knowledge
15
30%
A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND
Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND
A brief statement of pathophysiology is included for each diagnosis; AND
Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND
The differential is ranked in order from most likely to least likely; AND
Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND
Testing decisions are well supported with EBP arguments that are in-line with the clinical scenario and appropriate for the primary care setting
(7 critical elements)
Support from Evidence-Based Practice (EBP)
15
30%
Discussion post is supported with appropriate, scholarly sources; AND
Sources are published within the last 5 years (unless it is the most current CPG); AND
Reference list is provided and in-text citations match; AND
All testing decisions are fully supported with an appropriate EBP argument
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