Family Medicine 28 58-year-old male with shortness of breath

Family Medicine 28: 58-year-old male with shortness of breath
 
While working with your family medicine preceptor you are scheduled to see Mr. John Barley, a 58-year-old male who has sought medical attention only rarely in the past 10 years. He comes to the office today because of progressively worsening cough and shortness of breath during the previous month.
Before you and your preceptor Dr. Wilson enter the room to meet Mr. Barley, you think about the definition of dyspnea:
 
TEACHING POINT
Dyspnea Definition
Dyspnea is defined as an uncomfortable awareness of breathing.
Any problem in the mechanical system of breathing can trigger dyspnea, including (but not limited to):
·         blockage in the nose
·         fluid in the alveoli
·         irritation of the diaphragm
PATIENT HISTORY 1
 
Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.
You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you.” Mr. Barley says, “Sure, anyone working with Dr. Wilson is OK by me.”
You begin eliciting the history:
 
“I understand you have a cough and shortness of breath. Can you tell me more about it?”
“OK. Have you noticed anything else that seems to be related to the cough? Things like weight loss, chest pain, and fever?”
“Have you had any nausea, vomiting, or diarrhea?”
“Do you have shortness of breath when you are active and when you are at rest?”
“Have you had in the past, or currently have, exposures to things that can cause cough, like chemicals, and smoking?”
“Do you have any trouble lying flat when you sleep?”
 
You learn that he has not traveled recently, which could have exposed him to an unusual form of pneumonia. He also has not been exposed to tuberculosis. From other questions, you learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). You know that he has had no orthopnea.
As a farmer, he is active during the day. Deconditioning is not likely.
Wondering if his shortness of breath is due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes.
 
PATIENT HISTORY 2
HISTORY
Now that you have a good understanding of the history of the present illness, you continue the interview by turning to past medical, social, and family histories.
You say, “I think I have a clear idea about what brought you in today. Let me ask you now about your health in general.”
“Any serious illnesses in the past?”
“I’d like to ask about your personal life. Tell me about your home life.”
“Tell me about your immediate family health history.”
You say, “So I understand that you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes.”
 
 
 
INSTRUCTIONS
Assignment
Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 28: 58-year-old male with shortness of breath.
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
 
 
Submission Details:
• Post your initial response to the Discussion Area by Day 3. • Please make sure you are using scholarly references and they should not be older than 5 years. Your posts/references must be in APA format. • Please follow the discussion rubric to make sure you have addressed the discussion criteria.
 

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