Assessment. Differential diagnosis
Setting: large urban city family practice clinic which employs physicians and nurse practitioners.
It is Monday here at your clinic. In addition to your regularly scheduled you are being asked to add some additional patients. You note your next visit is a work-in for cough. You review the chart before entering the room to familiarize yourself with this patient’s chart. Katie has been coming to the clinic for years and she and her husband are well known to you but you still review the chart prior to entering the room to assure you are familiar with her history and previous visits. Most of her visits have been for yearly wellness checkups and her labs and vitals are great, even at age 65.
When you enter the room you see a well-dressed woman looking her stated age sitting on the exam table. Also present is a man who appears to be about 40, the woman introduces him as her son Patrick. Patrick has brought his mother in-law to the clinic today because he is concerned about her cough, it is not getting better. Katie says her son-in-law is worried for nothing but she has had the cough for a bit and it does not seem to be getting better at all.
HPI
Katie describes herself as normally really healthy. This cough started a week ago and it is worse at night. The cough wakes her up. Her chest is starting to hurt from all the coughing. She has noticed that she has been more tired and gets easily winded when she takes her daily walks. She has not gone to Curves this week like she usually does because she doesn’t have the energy. She doesn’t think she has fever, did not take her temperature.
PMH
Had chicken pox, measles and rubella as a child. Katie has a history of osteopenia, HTN and hyperlipidemia. Takes a daily multivitamin, Evista 60 mg daily and HCTZ 25 mg daily. No reports of past injuries. Previous surgeries include a tonsillectomy and cholecystectomy. Hospitalized for surgeries and childbirth. Has seasonal allergies to pollen and reports hayfever. She is allergic to Demerol, it makes her vomit. No alcohol or tobacco use.
Social
Married to John, they live with their married daughter and her family. Takes care of the kids and home as Mary and her husband work. Her husband and son-in-law both smoke, but not in the house.
Discussion Part One:
What further questions do you have for Katie at this visit??
Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature or the textbook. Include the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests would you order?
