Writing Homework Help

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:

1. 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.
2. 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.
3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely.
5. 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% 

1. A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND 
2. Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND 
3. A brief statement of pathophysiology is included for each diagnosis; AND 
4. Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND 
5. The differential is ranked in order from most likely to least likely; AND 
6. Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND 
7. Testing decisions are well supported with EBP arguments that are in-line with the clinical scenario and appropriate for the primary care setting