SCENARIO PROBLEM LIST  HISTORY

CASE 3              SCENARIO PROBLEM LIST  HISTORY  PHYSICAL EXAMINATION  DIFFERENTIAL DIAGNOSES

A 55-year-old man with cough, fever, and shortness of breath

John Kosich is a 55-year-old Russian man who presents with cough, fatigue, fever of 100℉, and increased SOB with activity for 5 days. The cough is productive, with a large amount of thick yellow/green sputum; the cough occurs day and night but is worse at night when supine. The patient needs two pillows to sleep at night. He experiences dyspnea with one flight of steps and intercourse. He has tried OTC cough syrup and Primatene Mist Inhaler with minimal relief.

Based on the information given, what are the patient problems?

What are significant questions in the history for the patient? What are the key points to cover in the review of systems?

What are the significant portions of the physical examination that should be completed for the patient? Include your rationale for each part of the physical exam.

List 4 minimum differential diagnosis. What are the significant positive and negative data that support or refute your diagnoses for the patient?

DIAGNOSTIC TESTS

Based on the history and physical exam, what, if any, diagnostic testing should be done? Include rationale and interpretation of the tests obtained.

DIAGNOSIS

What Final Diagnosis (es) do you determine as being appropriate for the patient? The data supporting this diagnosis and the pathophysiology of the condition.

THERAPEUTIC PLAN

1. What are the specific elements of the plan of care for treatment?
   1. Pharmacological and non-pharmacological treatments that may apply
   2. Any additional diagnostic tests needed to be ordered to confirm the final diagnosis?
2. What education needs to be provided for the patient and the family?
   1. To include Health promotion and
   2. Immunizations (if applicable)
3. Describe the need for consultation/collaboration (if applicable).
4. How soon should the patient return for follow-up?