Overview
GW, is a 40 y/o male seen in office with c/o cough x 3 days. Patient reports sore throat and chest pain when coughing. He reports feeling congested and feeling hot but did not check his temperature. He denies chills. He described his sputum as white to yellowish in color. He endorses SOB with ambulation. On assessment, patient’s left lungs positive for expiratory wheezing. His throat also appears mildly red. ZPAK x 1 and Zyrtec ordered for patient. Albuterol ordered for SOB/wheezing. CXR ordered to r/o bronchitis. F/u if symptoms worsen and as needed.
With this patient in mind, consider the following:
- Subjective: What details did the patient provide regarding his or her 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 and psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan 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: What was your “aha” moment? What would you do differently in a similar patient evaluation?