Question

1. A 29-year old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.

For the case you have chosen:

• Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
• In SOAP format, list:
  • Pertinent positive and negative information
  • Differential and working diagnosis
  • Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

In SOAP format, list: Pertinent positive and negative information Differential and working diagnosis Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

Answer 1

First establish whether the patient need urgent help or not.Then ask the present complaint.How she is feeling at the moment?How bad is the pain ? Do you feel breathless now?Ask if the cough productive or not. What is the color of sputum and any blood in sputum

History and Duration of the cough . With the history of the cough ask 1.Have you had shortness of breath in the past? Do you have a diagnosis of asthma or COPD .

2.Are you short of breath at rest or only during exertion? Can you manage walking stairs?

3.How long you have this symptoms

4.Do you feel like you are getting worse or better?

5.What are aggravating factors of the cough and other symptoms?

6 How long she has night sweats?

Ask her the family history and past medical medicine like medical conditions or previous surgery or any allergies

In Drug history: Ask about regular medication,inhalers she uses .is she uses Alcohol or smoke?

Physical examination:Take patient's blood pressure,heart rate,and Respiratory rate and temperature.

Examination of head and neck reveals the use of accessory muscles during the respiration.

Examination of the chest reveals use of accessory respiratory muscles.Breath sounds can be identified.ABCD assessment would cover all bases

Airway: Check the airway

Breathing: check oxygen saturation, respiratory rate

Circulation: Check heart sounds, blood pressure and peripheral oedema

Disability: Check the body temperature

Exposure: Check Abdomen for tenderness,bowel sounds

Investigations

1.Complete blood count:If she has any infection ESR will be raised .

2.Microscopy of sputum sample:If we are suspecting a pulmonary tuberculosis use Ziehl_Neelson method.If it's Positive mycobacteria are seen as pink rods against blue background.

3.Culture of sputum sample: Specimen should be cultured on special media containing antibiotics, specific growth factor and antifungals.

Imaging

1.Chest X-ray: Show fibrosis,consolidation and cavitation in tuberculosis.

2 CT chest: For better visualization of lesions in the lung

Differential diagnosis

1.Bacterial pneumonia

2.Aspergillosis

3 Histoplasmosis

4.Fungal pneumonia

5.Asthma