Assignment
Case:
Lou Brown is a 48-year-old white male who comes in seemingly in a hurry to be seen. He is not new to the clinic, however, you have not seen him before. His provider is on sick leave today. He begins to tell you all about himself before you ask the first question. He tells you he has been sick with a cough for the past two days. He says that the cough has been off and on. It started out as a dry cough but over the past two days, he has started coughing up thick pale-yellow phlegm. Sometimes his "breath gets short, especially after a cough". He thinks he has had a fever but he does not have a thermometer so has not actually checked his temperature. He is nauseated and has not eaten much. He wonders if his blood sugar might be normal since he is not eating much but he does not check it regularly since he has "the medicine for it." He is a smoker but has not been smoking very much since he has been feeling bad and very tired. He has been working at his job in the plant, where they make car parts until today, when he did not know if he could breathe wearing the mask he must wear at work. So, he decided he might be sick enough to get checked and his wife agreed. She told him she does not want to get sick herself because "she has to work." She was upset with him for "refusing booster shots but he said the plant did not force them to take the boosters, just the shots, and some guys said the boosters could make you sick." He has taken Tylenol off and on and it does help him "feel better ". About a week and a half ago, he played poker with some friends and one of them was sick. His wife told him he may have caught something from one of his buddies. She told him that he was "talking out of his head during the night". He has no memory of that.
PMH: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his provider on a regular basis, because he got a "years' worth of prescriptions for medicine from the provider he was seeing before the plant switched to this clinic".
Medications: lisinopril 20 mg daily; metformin 500 mg twice daily
Allergies: Penicillin
Immunizations: influenza, tetanus, smallpox, covid x 2
Social history: 30 pack year history of tobacco use (cigarettes); occasional beer with friends, no drugs. Machine operator in an industrial plant for 30 years where he has received a good attendance award most every year. Two adult children who are healthy. He was adopted so has no family history. He helps in the home as both he and his wife work. Their home is in a "good neighborhood" and they "work hard to keep it up." His hobby is "fishing in the summertime, but not much to do in the winter except watch sports on TV and then it is easy to pick up weight."
Vitals: Ht: 5'4"; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%
Task
A. Document additional history questions you would ask the patient. What questions would you ask related to the current complaint? What questions would you ask related to his comorbidities? What would you ask relative to his social determinants of health? Other relative history-related questions?
B. What Physical Exam would you obtain? Describe what you would be looking for.
C. What labs/diagnostics would you order?
D. List your top three differential diagnoses for the visit. Explain your rationale for your top diagnosis.
E. His lab tests include a Hgb of 13, WBC of 12,000 with a left shift, a BUN of 21, Glucose of 150, A1c of 10. What would you anticipate his Covid test would be? Anything else?
F. His chest x-ray shows L infiltrates.
G. Name health promotion topics that you would discuss with him. Would you suggest his wife be present for a future encounter?
H. Taking into consideration his social determinants of health, as well as his clinical presentation, what would your treatment plan be? What would your follow up plan be including any interprofessional referrals for this encounter?
I. Would the FQHC be an especially appropriate clinic for this patient? Why or why not?