Physical Diagnosis, Essay Example

Case Scenario: Mr. Jones is a 68-year old man who presents to the Emergency Department complaining of a cough.

Past medical/surgical history:  Hypertension; arthritis; knee replacement surgery one month ago; cigarette smoker x 50 years

Vital signs: BP 168/88 mmHg; HR 104 bpm, regular; RR 22 rpm; Temp 99.6°F  Pulse ox 94%

Differential Diagnoses: List 4 or more differential diagnoses that should be included for the above chief complaint.

Four or more differential diagnoses that could explain the chief complaint experienced by patient Mr. Jones:

1. The patient Mr. Jones might be experiencing a moderate to severe chest infection which could also be associated with a mild to severe case of pneumonia,
2. Jones might be experiencing an infective exacerbation of chronic airway limitation,
3. Jones might be experiencing a pulmonary embolis,
4. Jones could be experiencing a medication induced cough. This potentially medicated cough might also be exacerbated due to his smoking habit of over 50 years,
5. Jones might be experiencing a pulmonary oedema,

History: Use the space below to list the questions you would ask to obtain a full history of present illness (HPI)

Questions to ask the patient Mr. Jones:

• How heavy a smoker have you been for the past 50 years?(i.e. – how many packets of cigarettes do you smoke per day, and has it always been this amount over the 50 years?)
• How long have you had the coughfor?
• Is it a productive cough or a dry cough?
• What is the colour of the sputum if the cough is productive (i.e. – is it green or yellow in colour?)
• Have you ever experienced or had fevers whilst at home, and if so whendid they occur and for how long in duration?
• Do you use inhalers/ nebulizers at home for your cough? If so, what frequency is the usage, and what medicinal brand are they?
• Are you experiencing any other symptoms such as minor to severe chest pain, is there any shortness of breath that you experience, is there any minor to severe calf pain, pleurisy, or leg swelling?
• Have there been any investigations or procedures performed by your local doctor before your knee replacement? Have there been any procedures performed by your operating doctor while in hospital when you recently had the knee replacement?If so, what were the findings of such investigations or procedures?
• Have you had any recent changes or additions to any of your medications? If so, what are the exact details of these changes or additions? What are the doses and strengths of these changes?

Physical Exam: Use the space below to document your physical findings.  Use creativity to describe findings that you would expect with one of the diagnoses you listed above.  Indicate the diagnosis you chose at the end of your physical exam.

Physical findings:

• Tachycardic, febrile, dyspnoeic, dehydrated, cognitively intact
• Clear lung fields on auscultation
• Haemoptosis
• Jones is experiencing a tender calf muscle on his operated leg
• Jones has a swollen calf muscle with pitting oedema
• Jones’ wound has healed and there is no evidence of infection
• Jones is mobilisinghimself with a four wheeled walker

After analysing all of the available evidence, along with the patients’ symptoms plus recent physical findings, the diagnosis reached for Mr. Jones,is a Pulmonary Embolis