You see Mr. ABC a 34-year-old Hispanic male who presented with a complaint

Scenario: ED patient

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You see Mr. ABC a 34-year-old Hispanic male who presented with a complaint of severe dyspnea. He has been experiencing dyspnea for 2 weeks that has slowly, but progressively gotten worse. He was brought back immediately from triage because he has a respiratory rate of 40, an O2 sat of 88%, and a temperature of 101. His O2 sat has improved 92% on 4L of oxygen via NC. Review of symptoms if positive for fevers, chills, weight loss, malaise/fatigue, diaphoresis, cough, dyspnea, weakness, swelling in his lower extremities, feeling of abdominal fullness, and unintentional weight loss. He denies any other symptoms.

 

Past Medical History includes: Asthma

Past surgical: None

Social History: Single male, has sexual relations with men and women, denies smoking use. Has history of IV drug use but has not used for 5 years and used to be a heavy drinker for 10 years. Has not drank for 2 years.

 

Physical exam

Vitals: 110/60, 92% on 4L NC

Constitutional: Alert and oriented x 3. Thin.

Head: Normcephalic and atraumatic.

Eyes: PERRLA.

Oropharynx: White patches on tongue and buccal mucosa bilaterally

Cardio: 1+ pitting edema in lower extremities

Pulm/Chest: Lungs have rales in all lung fields

Abdominal: Round, distended, soft. Bowel sounds are active. No tenderness. Hepatosplenomegaly present. Shifting dullness. No rigidity, rebound or guarding.

Lymphy: Widely spread lymphadenopathy

Neuro: intact

Skin: a line of vesicles on the left thorax that extends from the anterior to posterior thorax

Psych: Mood and affect normal

 

Upon completing the history and physical Mr. ABC asks you: “What is wrong with me? Why am I sick? What do I need to do to get better? Your objective is to answer his questions.

 

1. Based on current information available, what diagnosis do you believe Mr. ABC has?

2. What labs and/or diagnostic tests do you believe are needed to confirm your diagnosis?

3. Describe the pathogenesis which explains this patient’s condition?

4. What education is important for Mr. ABC to receive?

Explanation & Answer

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