Case Study – Part 1
Date of visit: November 20
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.
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 … 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.
SOLUTION
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.
62-Year-old Caucasian male present to office with persistent cough onset 6 months ago, and recent onset of SOB, exacerbated by increased activity. The cough described as intermittent, productive with whitish- yellowish phlegm, and is more frequent in the morning. Endorsed to taking Robitussin DM without relief of symptoms. However, symptoms relieved by rest. Endorsed inability to walk >20ft without stopping to catch his breath but last year he routinely walked 1 mile per day without complications. Regarding the ROS, he denies constitutional illness of fever, chills, or weight loss. Denies Otalgia and otorrhea. Denies rhinorrhea, nasal congestion, sneezing or post-nasal drip. Denies ST and redness and lymph node tenderness or swelling. PMH significant for primary HTN and reports 20-year former smoker. Has an allergy to penicillin. Past surgical history of cholecystectomy and appendectomy. Vitals are as follows Temp 98.1, pulse 66, RR 20, BP 156/94, SPO2 94% RA. On physical exam- pt. Alert and oriented x4, in NAD, able to speak in full sentences. No abnormal heart sounds, lungs were clear, but with faint forced expiratory wheezes in bilateral bases appreciated. RR even and non-labored. No edema noted.
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
Dx1: Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease due to a combined process that causes….please click the purchase button below to access the entire solution at $15