Case Study NR 601 – Week 2 part
one
November 20, 2019
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. USE
SHORTHAND WHERE POSSIBLE AND APPROVED MEDICAL
ABBREVIATIONS. AVOID REDUNDANCY AND IRRELEVANT
INFORMATION
HPI
Pt is a 62-year-old male with a CC of persistence cough X 6 months and acute onset SOB. He
describes the cough as intermittent but more frequent in the AM. He characterizes his cough as
productive with white-yellow phlegm c/o. He identifies activity as an aggravating factor and has
experienced some relief with rest but has tried Robitussin DM with no relief from symptoms. He
denies chest pain, however he states that he has a decrease in activity tolerance in the last year
stating that he isn’t able to go more then 20 feet without stopping for breath.
Pertinent PMH
He has a history of primary hypertension and takes 50mg metoprolol succinate ER daily along
with a multivitamin. He is has an allergy to PNC accompanied by a rash. He has a hx of smoking
cigarettes 20 packs a year when he quite “cold turkey” after the death of his father. No illicit
drugs or alcohol use. He is married with 2 children and works as an accountant at a risk
management firm. His family hx includes the death of his father at 59 due to CHF and MI. His
father also suffered from diabetes, hypertension and smoking. His mother is still living and has
osteoporosis and his siblings are living and healthy.
Pertinent ROS findings:
The patient is + for persistent cough in AM x 6 months. + for productive whitish, yellow phlegm.
+SOB with activity. He is - for fever, chills, or weight loss. He is also - for otalgia, otorrhea,
rhinorrhea, congestion, sneezing or PND. He is - for ST or redness, lymph node tenderness, or
swelling, chest pain, or LE edema.
Pertinent PE findings:
Adult male, who is he is AAOx3, in NAD, + for complete sentences. Temp, RR, P are normal.
Patient is + for Obesity with BMI of 39.24. +for elevated BP at 156/94. +normocephalic. +
patent nares, + clear nasal turbinates, +clear nasal drainage bilaterally, - redness, - edema, OP +
moisture, - exudate or lesions. +tonsils at ¼, +normal dentation. Neck -for thyromegaly,
lymphadenopathy, or masses, - JVD. Heart sounds with +S1 and S2, -murmurs. +clear lung
1
, Case Study NR 601 – Week 2 part
sound bilaterally, -labored breathing. + faint forced expiratory wheezes bilaterally in the bases. –
one
labored respirations. -for lower extremity edema bilaterally. Abdomen is + softness,
-organomegaly, - abdominal tenderness.
2. PROVIDE A DIFFERENTIAL DIAGNOSIS (MINIMUM OF 3) WHICH
MIGHT EXPLAIN THE PATIENT'S CHIEF COMPLAINT ALONG WITH A
BRIEF STATEMENT OF PATHOPHYSIOLOGY FOR EACH.
2
one
November 20, 2019
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. USE
SHORTHAND WHERE POSSIBLE AND APPROVED MEDICAL
ABBREVIATIONS. AVOID REDUNDANCY AND IRRELEVANT
INFORMATION
HPI
Pt is a 62-year-old male with a CC of persistence cough X 6 months and acute onset SOB. He
describes the cough as intermittent but more frequent in the AM. He characterizes his cough as
productive with white-yellow phlegm c/o. He identifies activity as an aggravating factor and has
experienced some relief with rest but has tried Robitussin DM with no relief from symptoms. He
denies chest pain, however he states that he has a decrease in activity tolerance in the last year
stating that he isn’t able to go more then 20 feet without stopping for breath.
Pertinent PMH
He has a history of primary hypertension and takes 50mg metoprolol succinate ER daily along
with a multivitamin. He is has an allergy to PNC accompanied by a rash. He has a hx of smoking
cigarettes 20 packs a year when he quite “cold turkey” after the death of his father. No illicit
drugs or alcohol use. He is married with 2 children and works as an accountant at a risk
management firm. His family hx includes the death of his father at 59 due to CHF and MI. His
father also suffered from diabetes, hypertension and smoking. His mother is still living and has
osteoporosis and his siblings are living and healthy.
Pertinent ROS findings:
The patient is + for persistent cough in AM x 6 months. + for productive whitish, yellow phlegm.
+SOB with activity. He is - for fever, chills, or weight loss. He is also - for otalgia, otorrhea,
rhinorrhea, congestion, sneezing or PND. He is - for ST or redness, lymph node tenderness, or
swelling, chest pain, or LE edema.
Pertinent PE findings:
Adult male, who is he is AAOx3, in NAD, + for complete sentences. Temp, RR, P are normal.
Patient is + for Obesity with BMI of 39.24. +for elevated BP at 156/94. +normocephalic. +
patent nares, + clear nasal turbinates, +clear nasal drainage bilaterally, - redness, - edema, OP +
moisture, - exudate or lesions. +tonsils at ¼, +normal dentation. Neck -for thyromegaly,
lymphadenopathy, or masses, - JVD. Heart sounds with +S1 and S2, -murmurs. +clear lung
1
, Case Study NR 601 – Week 2 part
sound bilaterally, -labored breathing. + faint forced expiratory wheezes bilaterally in the bases. –
one
labored respirations. -for lower extremity edema bilaterally. Abdomen is + softness,
-organomegaly, - abdominal tenderness.
2. PROVIDE A DIFFERENTIAL DIAGNOSIS (MINIMUM OF 3) WHICH
MIGHT EXPLAIN THE PATIENT'S CHIEF COMPLAINT ALONG WITH A
BRIEF STATEMENT OF PATHOPHYSIOLOGY FOR EACH.
2
