ASSESSMENT 9 PATIENT NOTE: PRE-EMPLOYMENT CHECK-UP HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 32 YEAR OLD MALE COMES IN FOR A PRE-EMPLOYMENT CHECK UP. PATIENT REPORTS NO PMH, NO MEDICAL COMPLIANTS OR PROBLEMS. PATIENT REPORTS A PRODUCTIVE CHRONIC COUGH FOR MANY YEARS, WITH APPROXIMATELY A HANDFUL OF GREENISH YELLOW SPUTUM, NO BLOOD OR OTHER DISCHARGE. SOB WITH EXERTION, DYSPNEA AND MILD CHEST PAIN. DENIES BOWEL OR BLADDER CHANGES. PATIENT MOVED TO UNITED STATES ONE MONTH AGO FROM EUROPE, WORKS PREVIOUSLY AS A COAL MINER IN AFRICA, HAS NEVER HAD A PPD TEST. ROS:NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: NKDA MEDICATIONS: NONE PMH: NONE PSH: NONE FH: PARENTS ALIVE AND WELL SH: SMOKES 1 PPD FOR 10 YEARS, DENIES ETOH, DRUG USE, WORKS IN THE FIELD FOR AN OIL COMPANY, MARRIED LIVES WITH WIFE, IMMUNIZATIONS UP TO DATE. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. PATIENT IS IN NO ACUTE DISTRESS AND VITALS ARE WITHIN NORMAL LIMITS. HIS HEENT IS NORMOCEPHALIC AND ATRAUMATIC. HIS MOUTH AND THROAT ARE WITHIN NORMAL LIMITS. HIS NECK IS SUPPLE WITH NO LYMPHADENOPATHY. HIS BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY WITH NO WHEEZE OR RHONCHI. HIS HEART SOUNDS ARE NORMAL S1/S2 WITH NO RUBS, GALLOPS OR MURMURS. HIS ABDOMEN IS SOFT AND NONTENDER WITH BOWEL SOUNDS PRESENT. THERE IS NO CYANOSIS, CLUBBING OR EDEMA SEEN ON EXTREMITIES. HIS CN 2-12 ARE INTACT ON HIS NEUROLOGICAL EXAM WITH MOTOR STRENGTH 5/5 BILATERALLY. HIS REFLEXES ARE SYMMETRIC AND NORMAL GAIT. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.

Diagnosis #1: PULMONARY TUBERCULOSIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -PRODUCTIVE CHRONIC COUGH -PATIENT IS IN NO ACUTE DISTRESS FOR YEARS -GREENISH YELLOW SPUTUM -BREATH SOUNDS ARE CLEAR -PATIENT MOVED TO USA FROM -BOWEL SOUNDS ARE PRESENT EUROPE Diagnosis #2: CHRONIC BRONCHITIS HISTORY FINDING(S) -PRODUCTIVE CHRONIC COUGH FOR YEARS -GREENISH YELLOW SPUTUM -WORKS IN A COAL MINE Diagnosis #3: ASTHMA HISTORY FINDING(S) -CHRONIC COUGH FOR YEARS -WORKS IN A COAL MINE -SOB, DYSPNEA, CHEST PAIN

PHYSICAL EXAM FINDING(S) -PATIENT IS IN NO ACUTE DISTRESS -BREATH SOUNDS ARE CLEAR -BOWEL SOUNDS ARE PRESENT

PHYSICAL EXAM FINDING(S) -PATIENT IS IN NO ACUTE DISTRESS -BREATH SOUNDS ARE CLEAR -BOWEL SOUNDS ARE PRESENT

Diagnostic Studies: -CXR- PA AND AP VIEW -PPD TEST -SPUTUM GRAM STAIN -AFB SMEAR -CBC -MYCOBACTERIUM SPUTUM CULTURES