[SOLVED] Comprehensive Note
PMH: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his provider on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year so he has not run out of them.
Related: Tylenol
Medications: lisinopril 20 mg daily; metformin 500 mg twice daily
Allergies: Penicillin
Social history: 40 pack year history of tobacco use (cigarettes); no alcohol or drugs.
Vitals: Ht: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%
- Please document the history questions you would ask the patient.
- What Physical Exam would you obtain?
- What labs/diagnostics would you order?
- List your top four differential diagnoses. List your rationale for your top diagnosis.
- What is a CURB Score? (1 point)
A score to estimate the mortality of CAP to help determine inpatient vs. outpatient treatment.
- When his labs come back, his CMP shows that his BUN is 21. Based on that information and on his presentation, what is his CURB score and how did you arrive at that score?
- Based on his CURB score, should he be treated on an outpatient or inpatient basis?
- His chest x-ray does indeed show infiltrates. What is your treatment plan for him?
- Name 3 health promotion topics that you should discuss with him
- What is your follow up plan?
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