How to conduct a medical diagnosis of different medical conditions

 

Week 2 Case Scenarios

Case 1: 35-year old man with chronic cough

SUBJECTIVE

Chief complainant: Chronic cough

History of present illness: The patient who is a 35-year old man started experiencing chronic cough about one month ago.

Past history: None

Family history: N/A

Social history: Does not take drugs

Allergies: N/A

Medication history/review: None 

Review of systems (patient’s statements)

Constitutional/Gen: vomiting or lightheadedness 

2. HENT

2.1. Eyes: Confirms excellent eyesight

2.2. Ears: Denies hearing challenges

2.3. Nose: Denies sneezing or running nose

2.4. Throat: Throat irritation or cough congestion; positive

3. Cardiovascular: Acknowledges chest pain and discomfort 

4. Endocrine: Denies night sweats

5. Genitourinary: Denies any challenges when passing urine

6. Musculoskeletal: Denies back or joint pain

7. Skin/integumentary: Denies rashes, swelling or itching

8. Allergy/immunological: Denies asthma

9. Neurological: Acknowledges headache

10. Hematological: Denies bruising and bleeding

11. Psychiatric: Denies mood swings

OBJECTIVE

Physical exam

A. Vital signs: BP, Temperature, HR, RR

B. Visual acuity: 6/6

C. Physical examination

1. Constitutional/Gen: The patient is well-groomed and alert however, coughing makes it hard for him to communicate effectively.

2. Throat: The medical provider found sores in his throat which cause sore throats and discomfort

3. Cardiovascular: The health provider acknowledges chest tightness

4. Respiratory: The patient produces wheezing sounds and experiences shortness of breath

5. Neurological: The patient is oriented to person, time, and place

ASSESSMENT/IMPRESSION

Primary diagnosis

In this case, the primary diagnosis is Gastroesophagael reflux disease characterized by stomach acid refluxes into the esophagus which irritates the lining and triggers a cough (Morice et al., 2020). 

Differential diagnosis

I. Asthma

The disease may be misdiagnosed as asthma due to similarity in symptomatology. Similar to asthma, the patient was experiencing wheezing sounds and shortness of breath (Reteguiz, 2012). However, the condition will be ruled out during physical examination.  

II. Lung infections

The disease may be misdiagnosed as lung infections such as tuberculosis due to similarity in symptomatology. Similar to lung infections, the patient was experiencing chest pains.

PLAN

Diagnostic plan

A physical examination will be conducted with focus on the respiratory system of the patient to identify respiratory distresses and abnormal sounds. Also, chest X-ray will be conducted to identify any structural abnormalities (Stepinska et al., 2020). Besides, pulmonary function tests will be conducted to diagnose conditions such as asthma. A series of laboratory tests will be carried out such as complete blood count, sputum culture and sensitivity as well as acid reflux evaluation. 

Therapeutic plan

This treatment plan depends on the cause of the cough and aims to help patients manage chronic cough.

Follow up care/referral as applicable

The patient is required to attend all medical appointments to better their condition. Medical experts will monitor the patient’s response to medication and adjust the treatment plan according to the patient’s needs.

Patient education/health promotion

The patient will be educated on ways of preventing and managing the disease as well as receive counselling which will help the patient in coping with the disease and avoid self-blame.

Case 2: 26-year old woman with frequent chest pain

SUBJECTIVE

Chief complainant: Frequent chest pain

History of present illness: The patient who is a 26-year old woman started experiencing frequent chest pains about two months ago.

Past history: None

Family history: N/A

Social history: Does not take drugs

Allergies: N/A

Medication history/review: None 

Review of systems (patient’s statements)

Constitutional/Gen: vomiting, nausea, shortness of breath or dizziness

2. HENT

2.1. Eyes: Confirms excellent eyesight

2.2. Ears: Denies hearing challenges

2.3. Nose: Denies sneezing or running nose

2.4. Throat: Denies throat irritation or cough congestion

3. Cardiovascular: Acknowledges chest pain and discomfort 

4. Endocrine: Denies night sweats

5. Genitourinary: Denies any challenges when passing urine

6. Musculoskeletal: Denies back or joint pain

7. Skin/integumentary: Denies rashes, swelling or itching

8. Allergy/immunological: Denies asthma

9. Neurological: Denies headache

10. Hematological: Denies bruising and bleeding

11. Psychiatric: Denies mood swings

OBJECTIVE

Physical exam

A. Vital signs: BP, Temperature, HR, RR

B. Visual acuity: 6/6

C. Physical examination

1) Constitutional/Gen: The patient is well-groomed and alert however, regular chest pains makes it hard for her to communicate effectively.

2) Cardiovascular: The health provider acknowledges chest tightness and burning sensation in the chest

3) Respiratory: The patient experiences shortness of breath

4) Neurological: The patient is oriented to person, time, and place

ASSESSMENT/IMPRESSION

Primary diagnosis

In this case, the primary diagnosis is Gastroesophagael reflux disease characterized by stomach acid refluxes which causes a burning sensation in the chest hence, frequent chest pains (Reteguiz, 2012). 

Differential diagnosis

Angina

The disease may be misdiagnosed as Angina due to similarity in symptomatology. Similar to Angina, the patient was experiencing chest pains and feeling uncomfortable (Stepinska et al., 2020). However, the condition will be ruled out during physical examination.  

Anxiety or panic attacks

The disease may be misdiagnosed as anxiety or panic attacks due to similarity in symptomatology. Similar to anxiety or panic attacks, the patient was experiencing chest pains and shortness of breath.

PLAN

Diagnostic plan

A physical examination will be conducted to identify visible signs and symptoms such as swelling or abnormalities in the patient’s chest. Also, electrocardiogram test will be conducted to identify any signs of heart attack which are caused by angina conditions (Morice et al., 2020). Further, chest X-ray will be conducted to identify any structural abnormalities. Besides, exercise tolerance test will be conducted to assess how the patient’s heart responds to physical exertion (Reteguiz, 2012). A series of laboratory tests will be carried out such as acid reflux evaluation and CT scan or MRI. 

Therapeutic plan

This treatment plan depends on the cause of the chest pains and aims to help patients manage the condition.

Follow up care/referral as applicable

The patient is required to attend all medical appointments to better their condition. Medical experts will monitor the patient’s response to medication and adjust the treatment plan according to the patient’s needs.

Patient education/health promotion

The patient will be educated on ways of preventing and managing the disease as well as receive counselling which will help the patient in coping with the disease and avoid self-blame.

Case 3: 31-year old with difficulty “catching breath”

SUBJECTIVE

Chief complainant: Difficulty “catching breath”

History of present illness: The patient who is a 31-year old started experiencing difficulty “catching breath” about one and a half months ago.

Past history: None

Family history: N/A

Social history: Acknowledges smoking habits

Allergies: N/A

Medication history/review: None 

Review of systems (patient’s statements)

Constitutional/Gen: shortness of breath, bluish color to lips and face, increased pulse rate, decreased alertness

2. HENT

2.1. Eyes: Confirms excellent eyesight

2.2. Ears: Denies hearing challenges

2.3. Nose: Denies sneezing or running nose

2.4. Throat: Denies throat irritation or cough congestion

2.5. Mouth/lips: Acknowledges bluish color to lips

3. Cardiovascular: Acknowledges discomfort 

4. Endocrine: Denies night sweats

5. Genitourinary: Denies any challenges when passing urine

6. Musculoskeletal: Denies back or joint pain

7. Skin/integumentary: Denies rashes, swelling or itching

8. Allergy/immunological: Denies asthma

9. Neurological: Acknowledges headache

10. Hematological: Denies bruising and bleeding

11. Psychiatric: Denies mood swings

OBJECTIVE

Physical exam

A. Vital signs: BP, Temperature, HR, RR

B. Visual acuity: 6/6

C. Physical examination

1. Constitutional/Gen: The patient is well-groomed and alert however, shortness of breath makes it hard to communicate effectively.

2. Mouth/lips: The provider acknowledges bluish lips 

3. Cardiovascular: The health provider acknowledges chest tightness

4. Respiratory: The patient experiences shortness of breath

5. Neurological: The patient is oriented to person, time, and place

ASSESSMENT/IMPRESSION

Primary diagnosis

In this case, the primary diagnosis is Asthma characterized by inflammation and narrowed airways which lead to shortness of breath (Reteguiz, 2012).

Differential diagnosis

Heart conditions

The disease may be misdiagnosed as heart conditions due to similarity in symptomatology. Similar to heart conditions, the patient was experiencing shortness of breath (Reteguiz, 2012). However, the condition will be ruled out during physical examination.  

Chronic Obstructive Pulmonary Disease

The disease may be misdiagnosed as Chronic Obstructive Pulmonary Disease due to similarity in symptomatology. Similar to Chronic Obstructive Pulmonary Disease, the patient was experiencing breathing difficulties and discomfort.

PLAN

Diagnostic plan

A physical examination will be conducted with focus on the respiratory system of the patient to identify patient’s breathing pattern and respiratory distresses (Reteguiz, 2012). Also, chest X-ray will be conducted to identify any structural abnormalities in the patient’s lungs. Besides, pulmonary function tests will be conducted to diagnose conditions such as asthma. Lastly, an electrocardiogram test will be conducted to identify any heart abnormalities and assess the patient’s heart electrical activity. 

Therapeutic plan

This treatment plan depends on the cause of Difficulty “catching breath” condition and aims to helps the patient manage the medical condition.

Follow up care/referral as applicable

The patient is required to attend all medical appointments to better their condition. Medical experts will monitor the patient’s response to medication and adjust the treatment plan according to the patient’s needs.

Patient education/health promotion

The patient will be educated on ways of preventing and managing the disease as well as receive counselling which will help the patient in coping with the disease and avoid self-blame. Also, the patient will be educated on the dangers of smoking and how to prevent future smoking habits.

Case 4: 50-year old with 6-week history of shortness of breath

SUBJECTIVE

Chief complainant: history of shortness of breath

History of present illness: The patient who is a 50-year old has a history of experiencing shortness of breath within the last 6 weeks.

Past history: None

Family history: N/A

Social history: Does not use any drug

Allergies: N/A

Medication history/review: None 

Review of systems (patient’s statements)

Constitutional/Gen: shortness of breath, bluish color to lips and face, increased pulse rate, decreased alertness

2. HENT

2.1. Eyes: Confirms excellent eyesight

2.2. Ears: Denies hearing challenges

2.3. Nose: Denies sneezing or running nose

2.4. Throat: Denies throat irritation or cough congestion

2.5. Mouth/lips: Denies bluish color to lips

3. Cardiovascular: Acknowledges discomfort 

4. Endocrine: Denies night sweats

5. Genitourinary: Denies any challenges when passing urine

6. Musculoskeletal: Denies back or joint pain

7. Skin/integumentary: Denies rashes, swelling or itching

8. Allergy/immunological: Denies asthma

9. Neurological: Denies headache or any neurological conditions

10. Hematological: Denies bruising and bleeding

11. Psychiatric: Denies mood swings

OBJECTIVE

Physical exam

A. Vital signs: BP, Temperature, HR, RR

B. Visual acuity: 6/6

C. Physical examination

1. Constitutional/Gen: The patient is well-groomed, alert and communicates effectively.

2. Respiratory: The patient experiences shortness of breath

3. Neurological: The patient is oriented to person, time, and place

ASSESSMENT/IMPRESSION

Primary diagnosis

In this case, the primary diagnosis is Asthma characterized by inflammation and narrowed airways which lead to shortness of breath (Reteguiz, 2012).

Differential diagnosis

Heart conditions

The disease may be misdiagnosed as heart conditions due to similarity in symptomatology. Similar to heart conditions, the patient was experiencing shortness of breath (Reteguiz, 2012). However, the condition will be ruled out during physical examination.  

Chronic Obstructive Pulmonary Disease

The disease may be misdiagnosed as Chronic Obstructive Pulmonary Disease due to similarity in symptomatology. Similar to Chronic Obstructive Pulmonary Disease, the patient was experiencing breathing difficulties and discomfort.

PLAN

Diagnostic plan

A physical examination will be conducted with focus on the respiratory system of the patient to identify patient’s breathing pattern and respiratory distresses. Also, chest X-ray will be conducted to identify any structural abnormalities in the patient’s lungs (Reteguiz, 2012). Besides, pulmonary function tests will be conducted to diagnose conditions such as asthma. Lastly, an electrocardiogram test will be conducted to identify any heart abnormalities and assess the patient’s heart electrical activity. 

Therapeutic plan

This treatment plan depends on the condition of the patient and aims to helps the patient manage the medical condition.

Follow up care/referral as applicable

The patient is required to attend all medical appointments to better their condition. Medical experts will monitor the patient’s response to medication and adjust the treatment plan according to the patient’s needs.

Patient education/health promotion

The patient will be educated on ways of preventing and managing the disease as well as receive counselling which will help the patient in coping with the disease and avoid self-blame. 

Case 5: 50-year old woman requesting a blood pressure checked

SUBJECTIVE

Chief complainant: Blood Pressure

History of present illness: The patient who is a 50-year old woman has requested a blood pressure check-up.

Past history: None

Family history: N/A

Social history: Does not use any drug

Allergies: N/A

Medication history/review: None 

Review of systems (patient’s statements)

Constitutional/Gen: shortness of breath, severe headache, chest pain, dizziness, nausea, anxiety, blurred vision 

2. HENT

2.1. Eyes: Acknowledges blurred vision or vision changes

2.2. Ears: Denies hearing challenges

2.3. Nose: Denies sneezing or running nose

2.4. Throat: Denies throat irritation or cough congestion

2.5. Mouth/lips: Denies bluish color to lips

3. Cardiovascular: Acknowledges chest pains and discomfort 

4. Endocrine: Acknowledges night sweats

5. Genitourinary: Denies any challenges when passing urine

6. Musculoskeletal: Denies back or joint pain

7. Skin/integumentary: Denies rashes, swelling or itching

8. Allergy/immunological: Denies asthma

9. Neurological: Acknowledges headache 

10. Hematological: Denies bruising and bleeding

11. Psychiatric: Denies mood swings

OBJECTIVE

Physical exam

A. Vital signs: BP, Temperature, HR, RR

B. Visual acuity: 6/6

C. Physical examination

1. Constitutional/Gen: The patient is well-groomed, alert and communicates effectively.

2. Eyes: The patient experiences changed vision or blurred vision

3. Cardiovascular: The healthcare provider acknowledges chest pains and discomfort

4. Endocrine: The patient experiences night sweating often

5. Respiratory: The patient experiences shortness of breath

6. Neurological: The patient is oriented to person, time, and place

ASSESSMENT/IMPRESSION

Primary diagnosis

In this case, the primary diagnosis is measuring the patient’s blood pressure level (Flack & Adekola, 2020).

Differential diagnosis

Heart conditions

The disease may be misdiagnosed as heart conditions due to similarity in symptomatology. Similar to heart conditions, the patient was experiencing shortness of breath, chest pains, and discomfort (Reteguiz, 2012). However, the condition will be ruled out during physical examination.  

Anxiety or panic attacks

The disease may be misdiagnosed as anxiety or panic attacks due to similarity in symptomatology. Similar to anxiety or panic attacks, the patient was experiencing chest pains and shortness of breath.

PLAN

Diagnostic plan

A physical examination will be conducted which will include measuring the patient’s blood pressure on both arms, assessment of Body Mass Index and other signs and symptoms. In addition, accurate blood pressure measurement will be taken (Flack & Adekola, 2020). Besides, an electrocardiogram test will be conducted to identify any cardiac abnormalities and assess the patient’s heart electrical activity. A series of laboratory tests will be conducted such as Complete Blood Count, Lipid Profile, Electrolyte levels, HbA1c for diabetes assessment, and Basic Metabolic Panel (Reteguiz, 2012). However, if secondary hypertension is suspected, the patient will be subjected to secondary hypertension workup which will investigate specific causes of high blood pressure levels. 

Therapeutic plan

This treatment plan depends on the patient’s blood pressure levels and aims to helps the patient manage her condition. 

Follow up care/referral as applicable

The patient is required to attend all medical appointments to better their condition. Medical experts will monitor the patient’s response to medication and adjust the treatment plan according to the patient’s needs.

Patient education/health promotion

The patient will be educated on ways of preventing and managing the disease as well as receive counselling which will help the patient in coping with the disease and avoid self-blame. 

References

Flack, J. M., & Adekola, B. (2020). Blood pressure and the new ACC/AHA hypertension guidelines. Trends in cardiovascular medicine, 30(3), 160-164.

Morice, A. H., Millqvist, E., Bieksiene, K., Birring, S. S., Dicpinigaitis, P., Ribas, C. D., ... & Zacharasiewicz, A. (2020). ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. European Respiratory Journal, 55(1).

Stepinska, J., Lettino, M., Ahrens, I., Bueno, H., Garcia-Castrillo, L., Khoury, A., ... & Huber, K. (2020). Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. European Heart Journal: Acute Cardiovascular Care, 9(1), 76-89.

Reteguiz, J. A. (2012). Mastering the USMLE Step 2 CS. McGraw Hill Professional.