Lou Brown a 58 year old white male

Lou Brown 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? (1 point)

A score to estimate the mortality of CAP to help determine inpatient vs. outpatient treatment.

  1. 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?
  2.  Based on his CURB score, should he be treated on an outpatient or inpatient basis?
  3. His chest x-ray does indeed show infiltrates. What is your treatment plan for him?
  4.  Name 3 health promotion topics that you should discuss with him
  5. What is your follow up plan?

Here is the format (based on the rubric):

In the Subjective section, provide:

• Chief complaint

• History of present illness (HPI)

• Current medications

• Allergies

• Patient medical history (PMHx)

• Review of systems

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

In the Assessment section, provide:

• At least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

In the Plan section, provide:

• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.

• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.

• Reflections on the case describing insights or lessons learned.

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.

Complete Answer:

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