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.
Solution:
History and physical (H&P) findings
The patient is a 62-year old Caucasian male, who present to the primary care with a cough that started 6 months ago. He reports intermittent cough, productive with white-yellowish sputum. A factor that aggravates the cough is the activity, and cannot manage more than 20ft walking before he stops to catch a breath. This is a drastic change from last year as he could easily manage one mile without difficulty. The cough is worse in the morning and is relived with only rest and has tried using Robitussin DM to manage the symptoms. He has a height of 68.9in of weight 258 pounds, O2sat 94% on RA ….To access the solution click the icon below to purchase at $10