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%
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?

Please be sure to use in text citations and references

You should complete Focused SOAP note and then respond to questions at the end of Focused SOAP note. The information is not made up in SOAP note. You can indicate what questions you may ask or what additional assessment you may do on patient, but no patient information should be made up for SOAP note.

• Based on the provided patient information, think about the health history you would need to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
• Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
• Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
• Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with their condition(s).

The Assignment:

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 three. 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