Charles R. Drew University of Medicine and Science
Mervyn M. Dymally School of Nursing
NUR620: Advanced Physical Assessment and Clinical Diagnosis
Spring 2022
Patient Encounter Documentation Form
46-Year-Old Woman Complaining Of Fatigue And Weight Gain
Student’s Name: _________________________________Date: ______________ Score: ______ / 10
Subjective/Chief Complaint/History:
Chief Complaint: concise statement describing the symptom, problem, condition. medication refill/ follow up visit of established medical condition/care.
Fatigue and weight gain
History of present illness (HPI)
The patient reports feeling tired all the time and has gained 25 pounds in the last two months despite not eating much. The patient is always feeling cold, even during hot weather. Bowel movement is once a week. She has symptoms of depression and suffers from skin dryness. Most importantly, her family has a history of thyroid illnesses.
Past Medical History (PMI)
Family History
Social History
Allergies
Review of Systems
Objective/ Physical Examination (PE) Findings:
Vital Signs
Visual Acuity
Physical Examination
Constitutional/General
Head
Ears
Nose
Mouth/lip, Throat
Eyes
External eyes 1-4
Funduscopic Exam
Neck-Vascular
Cardiovascula
Respiratory
Abdomen
Genitourinary
Musculoskeletal
Lymphatics
Neurological
Skin/Integumentary
Psychiatric
The patient’s tongue is slightly enlarged; glands are normal and nontender; the heart rate is normal; there is a delayed relaxing phase in the arms and legs’ responses.
Assessment/Differential Diagnoses
Primary Diagnosis of the case (use ICD 10 coding guidelines)
Graves’ disease: The patient’s symptoms of skin dryness, weight changes, and depression are due to the enlarged thyroid gland caused by an autoimmune reaction (Smith & Hegedüs, 2016).
Hypothyroidism: The patient shows signs of hypothyroidism such as fatigue, weight gain, body aches, and intolerance to cold temperature (Chiovato et al., 2019).
Major depressive disorder (MDD): The patient shows signs of depressive disorder such as mood changes, loss of appetite, and lack of interest in pleasurable activities (Mahato & Paul, 2018).
Plan / Diagnostic Work-up/ Follow up/referral & Patient education/Health Promotion
Diagnostic Work-up: document test/ancillary procedures and results to support the chosen diagnosis (3-5 diagnosis)
Graves’ disease: Thyroid uptake scan, TSH in patient’s blood (Smith & Hegedüs, 2016).
Hypothyroidism: Thyroid function tests in serum and T4 level in the patient’s blood (Chiovato et al., 2019)
MDD: The patient needs psychiatric assessment and treatments (Mahato & Paul, 2018).
Therapeutic Plan/Treatment: medications and other treatment modalities/rationale for treatment
Graves’ disease: The condition is an autoimmune disorder. Treatment includes radioactive iodine or medication to reduce thyroid activity (Smith & Hegedüs, 2016).
Hypothyroidism: The patient must be treated with medications for life (Chiovato et al., 2019).
MDD: The patient needs continuous psychiatric treatment for her depressive disorder (Mahato & Paul, 2018).
Follow up:
The patient must be followed up every six weeks to monitor thyroid activity.
4. Referral & Patient education/Health Promotion:
The patient needs to be educated about the consequences of a delayed diagnosis to report any health changes immediately.
Patient Encounter Documentation Form
20-Year-Old Woman Complaining Of A Cough For 4 Days
Student’s Name: _________________________________Date: ______________ Score: ______ / 10
Subjective/Chief Complaint/History:
Chief Complaint: concise statement describing the symptom, problem, condition. medication refill/ follow up visit of established medical condition/care.
A cough that has lasted for four days
History of present illness (HPI):
The patient has a persistent cough that has lasted for four days. The cough is accompanied by green phlegm and a body temperature of 101.5°F. The patient reports that her colleagues at work have similar symptoms. The patient has a history of smoking, and a TB test she did two years ago came back positive.
Past Medical History (PMI)
Family History
Social History
Allergies
Review of Systems
Objective/ Physical Examination (PE) Findings:
Vital Signs
Visual Acuity
Physical Examination
Constitutional/General
Head
Ears
Nose
Mouth/lip, Throat
Eyes
External eyes 1-4
Funduscopic Exam
Neck-Vascular
Cardiovascula
Respiratory
Abdomen
Genitourinary
Musculoskeletal
Lymphatics
Neurological
Skin/Integumentary
Psychiatric
Objective/ Physical Examination (PE) Findings:
The patient has no swollen glands, no erythema or exudate in his throat, no tenderness over his maxillary sinuses, the patient’s back moves side to side with taps on the left and right sides of her back, there are positive “e” to “a” changes, and positive whispered pectoriloquy at the right base
Assessment/Differential Diagnoses
Primary Diagnosis of the case (use ICD 10 coding guidelines)
Bronchiectasis: The patient may have bronchiectasis, which is the dilation of the airways due to obstruction caused by mucus, pus, or tumors (Chalmers et al., 2018).
Chronic cough variant asthma: The patient is likely to be suffering from chronic variant asthma, which is not like classic asthma but accompanied by a cough that lasts for over six weeks (Enseki et al., 2019).
Pertussis: The patient may be suffering from pertussis, an acute infectious disease characterized by severe coughing (Merkel, 2019).
Plan / Diagnostic Work-up/ Follow up/referral & Patient education/Health Promotion
Diagnostic Work-up: document test/ancillary procedures and results to support the chosen diagnosis (3-5 diagnosis)
Bronchiectasis: The patient will need an imaging lung scan to check if any lung lesions need further investigation (Chalmers et al., 2018).
Chronic cough variant asthma: The patient will need a spirometry test to measure airflow obstruction (Enseki et al., 2019).
Pertussis: The patient will need a PCR and serology if diagonise pertussis (Merkel, 2019).
Therapeutic Plan/Treatment: medications and other treatment modalities/rationale for treatment
Bronchiectasis: The patient will need bronchodilators to reduce airflow obstruction (Chalmers et al., 2018).
Chronic cough variant asthma: The patient needs anti-inflammatory medication and beta-agonist inhalers (Enseki et al., 2019).
Pertussis: The patient needs antibiotics (Merkel, 2019).
Follow up:
The patient needs to be followed for three months to monitor lung function tests.
Referral & Patient education/Health Promotion:
The patient must quit smoking. A rehabilitation program may help
Patient Encounter Documentation Form
25-Year-Old Man Complaining Of A Sore Throat
Student’s Name: _________________________________Date: ______________ Score: ______ / 10
Subjective/Chief Complaint/History:
Chief Complaint: Sore throat
History of present illness (HPI):
The patient has a sore throat that has lasted for seven days. He also has a fever (101.5°F) and reports swollen and tender neck glands. The patient also reports loss of appetite and a feeling of a swollen abdomen. The patient’s girlfriend also reports similar symptoms. However, he expressed having to risk hepatitis A and B.
Objective/ Physical Examination (PE) Findings:
The pharynx is erythematous, the neck is tender to palpation, and tenderness on the right upper side of the abdomen and spleen area.
Assessment/Differential Diagnoses
Group ‘A’ beta-hemolytic streptococcus (GABHS): GABHS may cause pharyngitis with high fever, headache, abdominal pain, nausea, vomiting, and malaise after an incubation of 2 – 5 days (Kalra et al., 2016).
Cat Scratch Disease (CSD): CSD may cause fever, malaise, regional lymphadenopathy, and a painful lymph node with ulceration at the site of inoculation (Habot-Wilner et al., 2018).
Mononucleosis: Mono, also known as glandular fever, may influence fever, fatigue, sore throat, and also enlarged lymph nodes in the neck (Naughton et al., 2021).
Plan / Diagnostic Work-up/ Follow up/referral & Patient education/Health Promotion
Diagnostic Work-up:
GABHS: The patient will need a rapid test for strep to diagnose if it is GABHS (Kalra et al., 2016).
CSD: The patient may need a serology to diagnose CSDs (Habot-Wilner et al., 2018).
Mononucleosis: The patient will need Blood tests checking for the presence of adenovirus, Epstein-Barr virus, and cytomegalovirus in blood to diagnose if it is mono (Naughton et al., 2021)
Treatment:
GABHS: The patient will need antibiotics such as penicillin or amoxicillin (Kalra et al., 2016).
CSD: The patient will need antibiotics if the cat scratch causes an abscess to form in the area of inoculation (Habot-Wilner et al., 2018).
Mononucleosis: The patient needs steroid medicine for three weeks to reduce the swelling in lymph nodes (Naughton et al., 2021).
Follow up:
The patient needs to be followed for two weeks until his fever has resolved.
Referral & Patient education/Health Promotion:
The patient needs to maintain fluid intake and rest. He also needs to avoid strenuous activity. Safe sex, body, and food hygiene should be maintained.
Patient Encounter Documentation Form
40-Year-Old Man Complaining Of Abdominal Pain
Student’s Name: _________________________________Date: ______________ Score: ______ / 10
Subjective/Chief Complaint/History:
Chief Complaint: Abdominal pain
History of present illness (HPI):
The patient has been experiencing abdominal pain for the last two days. He rates the pain ten on a scale of 1 to 10. He is vomiting but has no diarrhea or constipation. His urine is yellow, and eating anything makes the pain worse. Lying on the side helps but lying on his back worsens the pain. The patient drinks ten beers a day and sustained pancreatitis because of drinking two years ago.
Objective/ Physical Examination (PE) Findings:
BP orthostatic changes are present, normal conjunctivae and sclerae, Cullen’s sign, and epigastric pain when the abdomen is palpated
Assessment/Differential Diagnoses
Pancreatitis: The patient has signs of pancreatitis with abdominal pain, vomiting, and elevated lipase levels (Anderson & Trujillo, 2010).
Biliary Colic: Patients have similar symptoms but are older than 50 years old with no history of heavy alcohol intake (Baiu & Hawn, 2018).
Appendicitis: The patient has a high fever, nausea, and vomiting, which can be signs of appendicitis (Becker et al., 2018).
Plan / Diagnostic Work-up/ Follow up/referral & Patient education/Health Promotion
Diagnostic Work-up:
Pancreatitis: Lab tests will include amylase/lipase levels, serum white blood cell count, urinalysis, and abdominal X-ray to diagnose if it is pancreatitis (Anderson & Trujillo, 2010).
Biliary Colic: Lab tests will include abdominal ultrasound, liver function test, and cholangiography to confirm the diagnosis (Baiu & Hawn, 2018).
Appendicitis: The patient will need a CT-scan and lab tests to diagnose appendicitis (Becker et al., 2018).
Treatment:
Pancreatitis: The patient needs to stop drinking alcohol. He also needs IV antibiotics for 48 hours, pain medication, and oral medications for recovery (Anderson & Trujillo, 2010).
Biliary Colic: If the diagnosis is biliary colic, the patient needs to avoid fatty foods and medications. He also needs an ultrasound of the abdomen, gallbladder drainage if necessary, and pain killers for recovery (Baiu & Hawn, 2018).
Appendicitis: The patient needs surgery to remove the appendix (Becker et al., 2018).
Follow up:
The patient will be followed for two weeks until his fever has resolved. He can then follow up with his primary care physician.
Referral & Patient education/Health Promotion:
The patient needs to maintain fluid intake and rest. He also needs to avoid strenuous activity.
Patient Encounter Documentation Form
48-Year-Old Man With Chest Pain
Student’s Name: _________________________________Date: ______________ Score: ______ / 10
Subjective/Chief Complaint/History:
Chief Complaint: Chest Pain
History of present illness (HPI):
The patient has had chest paints that tend towards his right arm in the last one hour. The rates the pain seven on a scale of one to 10. The patient has been smoking for the previous ten years, takes alcohol occasionally, does not exercise, and works at wall street, which is a stressful job. The patient father and brother died of a heart attack before age 60.
Objective/ Physical Examination (PE) Findings:
No jugular venous distention, lung and heart examination is normal, and palpate PMI is also normal.
Assessment/Differential Diagnoses
Unstable angina: The pain occurs in the last hour, is mainly located in the arm, systolic blood pressure decreases with exertion and is relieved by rest (Puelacher et al., 2019).
Acute coronary syndrome: Patients usually have elevated cardiac enzymes, which indicate myocardial injury (Katus et al., 2017).
Catecholamine-induced cardiomyopathy: Catecholamine-induced cardiomyopathy is a rare condition that occurs when “fight or flight” hormones are released excessively and may lead to heart failure in some cases. While the disease is rare, it is vital to be aware of the signs and symptoms so that you can get help if needed (Santos et al., 2018).
Plan / Diagnostic Work-up/ Follow up/referral & Patient education/Health Promotion
Diagnostic Work-up:
Unstable angina: Lab tests will include troponin levels ECG to confirm (Puelacher et al., 2019).
Acute coronary syndrome: Lab tests will include cardiac enzymes and troponin levels (Katus et al., 2017).
Catecholamine-induced cardiomyopathy: Lab tests will include beta-blocker eye drops to confirm the diagnosis (Santos et al., 2018).
Treatment:
Unstable angina: The patient needs aspirin, statin, and nitrate therapy for chest pain (Puelacher et al., 2019).
Acute coronary syndrome: The patient needs an emergency stent to be placed (Katus et al., 2017).
Catecholamine-induced cardiomyopathy: The patient needs beta blocker eye drops (Santos et al., 2018).
Follow up:
The patient will need to return to the hospital if he has any other symptoms. He also needs a test for cardiac enzymes and troponin levels.
Referral & Patient education/Health Promotion:
The patient needs to avoid smoking and should exercise regularly. He also needs a stress test in the next six months.
References
Anderson, S. L., & Trujillo, J. M. (2010). Association of pancreatitis with glucagon-like peptide-1 agonist use. Annals of Pharmacotherapy, 44(5), 904-909. https://doi.org/10.1345/aph.1m676
Baiu, I., & Hawn, M. T. (2018). Gallstones and biliary colic. JAMA, 320(15), 1612. https://doi.org/10.1001/jama.2018.11868
Becker, P., Fichtner-Feigl, S., & Schilling, D. (2018). Clinical management of appendicitis. Visceral Medicine, 34(6), 453-458. https://doi.org/10.1159/000494883
Chalmers, J. D., Chang, A. B., Chotirmall, S. H., Dhar, R., & McShane, P. J. (2018). Bronchiectasis. Nature Reviews Disease Primers, 4(1). https://doi.org/10.1038/s41572-018-0042-3
Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in context: Where we’ve been and where we’re going. Advances in Therapy, 36(S2), 47-58. https://doi.org/10.1007/s12325-019-01080-8
Enseki, M., Nukaga, M., Tadaki, H., Tabata, H., Hirai, K., Kato, M., & Mochizuki, H. (2019). A breath sound analysis in children with cough variant asthma. Allergology International, 68(1), 33-38. https://doi.org/10.1016/j.alit.2018.05.003
Habot-Wilner, Z., Trivizki, O., Goldstein, M., Kesler, A., Shulman, S., Horowitz, J., Amer, R., David, R., Ben-Arie-Weintrob, Y., Bakshi, E., Almog, Y., Sartani, G., Vishnevskia-Dai, V., Kramer, M., Bar, A., Kehat, R., Ephros, M., & Giladi, M. (2018). Cat-scratch disease: Ocular manifestations and treatment outcome. Acta Ophthalmologica, 96(4), e524-e532. https://doi.org/10.1111/aos.13684
Kalra, G., Higgins, E., & Perez, D. (2016). Common questions about streptococcal pharyngitis. American family physician, 94(1), 24-31. https://www.aafp.org/afp/2016/0701/p24.html?utm_medium=email&utm_source=transaction
Katus, H., Ziegler, A., Ekinci, O., Giannitsis, E., Stough, W. G., Achenbach, S., Blankenberg, S., Brueckmann, M., Collinson, P., Comaniciu, D., Crea, F., Dinh, W., Ducrocq, G., Flachskampf, F. A., Fox, K. A., Friedrich, M. G., Hebert, K. A., Himmelmann, A., Hlatky, M., … Semjonow, V. (2017). Early diagnosis of acute coronary syndrome. European Heart Journal, 38(41), 3049-3055. https://doi.org/10.1093/eurheartj/ehx492
Mahato, S., & Paul, S. (2018). Electroencephalogram (EEG) signal analysis for diagnosis of major depressive disorder (MDD): A review. Nanoelectronics, Circuits and Communication Systems, 323-335. https://doi.org/10.1007/978-981-13-0776-8_30
Merkel, T. J. (2019). Toward a controlled human infection model of pertussis. Clinical Infectious Diseases, 71(2), 412-414. https://doi.org/10.1093/cid/ciz842
Naughton, P., Healy, M., Enright, F., & Lucey, B. (2021). Infectious mononucleosis: Diagnosis and clinical interpretation. British Journal of Biomedical Science, 78(3), 107-116. https://doi.org/10.1080/09674845.2021.1903683
Puelacher, C., Gugala, M., Adamson, P. D., Shah, A. S., Chapmann, A. R., Anand, A., Boeddinghaus, J., Nestelberger, T., Twerenbold, R., Wildi, K., Rubini Gimenez, M., Osswald, S., Mills, N. L., & Mueller, C. (2019). P1695Incidence and outcomes of unstable angina compared to non-ST elevation myocardial infarction. European Heart Journal, 40(Supplement_1). https://doi.org/10.1093/eurheartj/ehz748.0450
Santos, J. R., Brofferio, A., Viana, B., & Pacak, K. (2018). Catecholamine-induced cardiomyopathy in Pheochromocytoma: How to manage a rare complication in a rare disease? Hormone and Metabolic Research, 51(07), 458-469. https://doi.org/10.1055/a-0669-9556
Smith, T. J., & Hegedüs, L. (2016). Graves’ disease. New England Journal of Medicine, 375(16), 1552-1565. https://doi.org/10.1056/nejmra1510030