COMPLEX CASE STUDY

COMPLEX CASE STUDY

Lou Brown is a 58 year old white male who comes in with a cough for the past four days.  He says that the cough has been intermittent.  It started out as a dry cough but over the past two days, he has started coughing up thick pale yellow phlegm.  He thinks he has had a fever but he has not actually taken his temperature.  He is a smoker but has not been smoking very much the past few days as that seems to make the cough worse.  He has also felt very tired.  He has taken Tylenol off and on and it does help slightly.  About a week and a half ago, he played poker with some friends and one of them was sick.  His wife accompanies him and when you ask them both, they deny that he has had any confusion.

PMH:  History of Hypertension and Diabetes Mellitus Type 2.  He admits he has not been going to his provider on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year so he has not run out of them.

Medications:  lisinopril 20 mg daily; metformin 500 mg twice daily

Allergies:  Penicillin

Social history: 40 pack year history of tobacco use (cigarettes); no alcohol or drugs.

Vitals:  Ht: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%

1.      Please document the history questions you would ask the patient.

2.      What Physical Exam would you obtain?

3.      What labs/diagnostics would you order?

4.      List your top four differential diagnoses.  List your rationale for your top diagnosis.

5.      What is a CURB Score?

6.      When his labs come back, his CMP shows that his BUN is 21.  Based on that information and on his presentation, what is his CURB score and how did you arrive at that score? 

7.      Based on his CURB score, should he be treated on an outpatient or inpatient basis?

8.      His chest x-ray does indeed show infiltrates.  What is your treatment plan for him?

9.      Name 3 health promotion topics that you should discuss with him

10.   What is your follow up plan?

 

*Note that the information provided is meant to be the basis of a SOAP note and does not included complete details.  Any missing information that is not provided should be created or made up by you in order to submit a complete note.  You must answer ALL of the questions either in the note or in a separate document.  Please adhere to APA formatting for a title page, in-text citations, and references.  You may use a mnemonic to develop the HPI, but the information should be incorporated into a narrative or paragraph, not listed out.

 

Assignment: Assessing, Diagnosing, and Treating Patients With Complex Conditions

For this Assignment, you will be assigned a complex patient case study with conditions related to any of the topics covered in Weeks 4–6. This includes cardiovascular, pulmonary, gastrointestinal

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