Today you are off from the clinic and are covering a shiftin the emergency room department. You goto see Mr. ABC a 34-year-old Hispanic male who presented with a compliant ofsevere dyspnea. He has been experiencingdyspnea for 2 weeks that has slowly, but progressively gotten worse. He was brought back immediately from triagebecause he has a respiratory rate of 40, an 02 sat of 88%, and a temperature of101. His o2 sat has improved 92% on 4 Liters of oxygen via N.C. Rzeview of symptoms is positive for fever, chills,weight loss, malaise/fatigue, diaphoresis, cough, dyspnea, weakness, swellingin his lower extremities, feeling of abdominal fullness, and unintentional weightloss. He denies any other symptoms. Past medical History includes Asthma. Pastsurgical history, none. Social history,single male, has sexual relations with men and women, denies smoking use. Has a history of iv drug use but has not usedfor 5 years and used to be a heavy drinker for 10 years. He has not drank for 2 years.
Physical Exam
Vital signs temp 101,heart rate 120, resp rate 38 blood pressure 110/60, o2 sat 92% on 4 liters N.C.
Constitutional: Alert and oriented x 3. Thin.
Head: Normocephalic and atraumatic
Eyes: Pupils are equal, round, and react to light. Nonystagmus. No scleral icterus.
Oropharynx: White patches on tongue and buccal mucosabilateral
Neck: neck supple. No JVD present. No tracheal deviation present.No thyromegaly or thyroid nodules noted.
Cardiovascular :Normal rate, S1 normal, S2 present, withoutS3, S4 gallop, friction rub or murmur. 1+ pitting edema to lower extremities.
Pulses: brachial, radial, dorsalis pedis, and posteriortibial pulses are 2+/4+ bilaterally.
Pulmonary/chest: Dyspneic. Respirations regular andeven. Lungs have rales in all lung fields.
Abdominal: round, distended, soft. Bowel sounds are active. No mases noted. No CVAtenderness. Hepatosplenomegaly present. Shifting dullness. There is norigidity, rebound, or guarding.
Lymph: has widely spread lymphadenopathy.
Neurological: Cranial Nerves II-XII intact.
Skin: skin is warm, dry and intact. A line of vesicles on the left thorax thatextends from the anterior to posterior thorax.
Psychiatric: mood and affect notrmal. Calm and cooperativebehavior. Judement intact.
MR. ABCs Questions
Upon completing the history and physical Mr. ABC asks,you: Whatis wrong with me? Why am I sick? What do I need to do to get better? Your objective is to answer Mr. ABCsquestions. To answer his questionscompletely, you must integrate the answers to the questions below into yourresponse to Mr. ABC. Your response shoulddemonstrate that you are speaking with Mr. ABC as though you were in the roomwith him.
1. Based on the current information available, whatdiagnosis do you believe Mr. ABC has? While your diagnosis still need to beconfirmed, you have enough information to know what is wrong with Mr. ABC.
2. What labs and/or diagnostic tests do you believeare needed to confirm your diagnosis?
3. Describe the pathogenesis which explains thepatients condition?
4. What education is important for Mr. ABC to receive?
Must use terminology appropriate for the target audience . all questions must be answered. WIll have to make a video so responses have to be less than 7 min in total
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