Purpose

Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice. The purpose of this activity is to develop students’ clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group.

Activity Learning Outcomes

Through this discussion, the student will demonstrate the ability to:

Demonstrate competence in the evaluation and management of common respiratory problems (WO 2.1)  (CO,2,3,4,5)
Distinguish between obstructive and restrictive lung disease (CO 2, 4) Develop a management plan for the case study patient based on identified primary, secondary and differential diagnoses. (WO 2.2) (CO 2,4)
Interpret pulmonary function test results. (WO 2.3) (CO 2, 4)

Due Date:

Student enters initial post to part one by 11:59 p.m. MT on Tuesday; responds substantively to at least one topic-related post of a peer including evidence from appropriate sources AND all direct faculty questions in parts one by Sunday, 11:59 p.m. MT.

A 10% late penalty will be imposed for discussions posted after the deadline on Tuesday 11:59pm MT, regardless of the number of days late. NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0).

Total Points Possible: 50

Case Study – Part 1

Date of visit: November 20,2019

A 62 year-old Caucasian male presents to the office with persistent cough and recent onset of shortness of breath. Upon further questioning you discover the following subjective information regarding the chief complaint.

History of Present Illness
Onset	6 months
Location	Chest
Duration	Cough is intermittent but frequent, worse in the AM
Characteristics	Productive; whitish-yellow phlegm
Aggravating factors	Activity
Relieving factors	Rest
Treatments	Tried Robitussin DM without relief of symptoms
Severity	Unable to walk > 20ft without stopping to catch his breath. Last year at this time he routinely walked 1 mile per day without difficulty
Review of Systems (ROS)
Constitutional	Denies fever, chills, or weight loss
Ears	Denies otalgia and otorrhea
Nose	Denies rhinorrhea, nasal congestion, sneezing or post nasal drip.
Throat	Denies ST and redness
Neck	Denies lymph node tenderness or swelling
Chest	Describes a persistent productive cough upon wakening for the last 6 months. Color of phlegm is usually white-yellowish. Shortness of breath with activity.
Cardiovascular	Denies chest pain and lower extremity edema

History
Medications	Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamin daily
PMH	Primary hypertension
PSH	Cholecystectomy, appendectomy
Allergies	Penicillin (hives)
Social	Married, 3 children Senior accountant at a risk management firm
Habits	Former smoker (20 pack-year), quit “cold turkey” when father died; Denies alcohol or illicit drug use.
FH	Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker) Mother is alive (osteoporosis) Healthy siblings

Physical exam reveals the following:

Physical Exam
Constitutional	Adult male in NAD, alert and oriented, able to speak in full sentences
VS	Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA
Head	Normocephalic
Ears	Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.
Nose	Nares patent. Nasal turbinates clear without redness or edema. Nasal drainage is clear.
Throat	Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.
Neck	Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. No JVD
Cardiopulmonary	Heart S1 and S2 with no murmurs, noted. Lungs clear to auscultation bilaterally with faint forced expiratory wheezes in bilateral bases. Respirations unlabored. Legs without edema.
Abdomen	Soft, non-tender. No organomegaly

Requirements/Questions:

Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. May use approved medical abbreviations. Avoid redundancy and irrelevant information.
Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement (2-3 sentences) of pathophysiology for each.
Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
Rank the differential in order of most likely to least likely.
Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based practice (EBP) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBP evidence.

Solution:

History and Physical Assessment (H&P)

The client presented complains of an intermittent cough that worsens in the morning. The patient experiences shortness of breath during activity but becomes relieved after resting. The patient has tried to use Robitussin DM without any improvement. Moreover, he experiences difficulties in climbing stairs or walking over long distances. For the last six months, the client has had a persistent cough with white-yellow phlegm. In addition to the cough, the patient often has shortness of breath. His records indicate the use of Metoprolol succinate ER (Toprol-XL) for treating primary hypertension. Other past medical conditions include Cholecystectomy and appendectomy. Although the client denies alcohol or illicit drugs, he was a chronic smoker. Concerning his family history, the patient’s siblings are healthy, although the father died of MI & CHF at the age of 59 years. The mother is still alive but has osteoporosis. Upon the physical examination, the patient’s throat was moist and in good condition. However, the Cardiopulmonary showed the presence of Heart S1 and S2 with no murmurs. Likewise, the lungs produced faint wheezes on bilateral bases. The respirations were reasonable, and the legs do not have Edema. All other systems were standard, including stomach, neck, head, and ear.

Differential Diagnosis

COPD

Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema, and chronic obstructive airways disease. Individuals… Please click the icon below to purchase full answer at only $10