Case Study: Assessing, Diagnosing, and Treating Patients With Complex Conditions

Use the Focused SOAP Note Template to address the following:

• Subjective: What details are provided regarding the patient’s personal and medical history?
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
• Assessment: Explain your differential diagnoses, providing a minimum of four. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
• Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

• Reflection notes: Describe your “aha!” moments from analyzing this case.

THE 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%

Address each of the questions:

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.

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?