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:

1. Demonstrate competence in the evaluation and management of common respiratory problems (WO 2.1)  (CO,2,3,4,5) 
2. 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)  
3. 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:

1. 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.
2. 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.
3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely.
5. 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.

 

DISCUSSION CONTENT  Category  Points  %  Description  Application of Course Knowledge  15  30%  A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND  Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND  A brief statement of pathophysiology is included for each diagnosis; AND  Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND  The differential is ranked in order from most likely to least likely; AND  Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND  Testing decisions are well supported with EBP arguments that are in-line with the clinical scenario and appropriate for the primary care setting  (7 critical elements)  Support from Evidence-Based Practice (EBP)  15  30%  Discussion post is supported with appropriate, scholarly sources; AND   Sources are published within the last 5 years (unless it is the most current CPG); AND  Reference list is provided and in-text citations match; AND  All testing decisions are fully supported with an appropriate EBP argument  (4 critical elements)  Interactive Dialogue  10  20%  Student provides a substantive* response to at least one topic-related post of a peer; AND  Evidence from appropriate scholarly sources are included; AND  Reference list is provided and in-text citations match; AND  Student responds to all direct faculty questions   (*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response  (4 critical elements)        Total CONTENT Points= 40 pts  DISCUSSION FORMAT  Category  Points  %  Description  Organization  5  10%  Case study response is presented in a logical format, AND  Responses are in sequence with the numbered questions AND The case study response is understandable and easy to follow AND  All responses are relevant to the case topic  (4 critical elements)  Grammar, Syntax, Spelling & Punctuation  5  10%  Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors*          Total FORMAT Points= 10 pts        DISCUSSION TOTAL= 50 pts  SOLUTION Sixty-two y/o male with chronic cough x six weeks with new recent onset of SOB, exacerbated with exercise for example walking > 20ft, relieved with sleep. Cough even worse in the early morning and it is intermittent and frequent. Cough is effective with a whitish/ yellow-colored phlegm. Pt has experimented with cough syrup without any help. No nasal or even sinus symptoms, HEENT regular examination, Afebrile, Normal VS, O sat 94% on RA, Lungs distinct bilat with weak forced expiratory wheezes noted. Former smoker of twenty yrs. Family hx of htn and heart disease. Pt has htn, takes metoprolol succinate ER fifty mg daily, BP 156/94 today. Differential Diagnosis, , Pathophysiology Diagnostics #1. Chronic Obstructive Pulmonary Disease: lung disease with persistent respiratory problems that progress. May be genetically predisposed. Deadly inhalants for example tobacco smoke produce airway inflammation as a result of airflow being reduced from airway deformity triggered type poisonous substances, producing mucous hypersecretion (GOLD, 2017). Affected person has had a cough for six weeks, with completely new onset SOB exacerbated with activity and relieved with sleep. Sputum creation whitish/ yellow. Afebrile, O sat ninety four % on space air. No sinusitis or even rhinitis patient. Former smoker of twenty years, with this particular hx affected person is in danger for COPD. Based on Clinical practice guidelines for COPD, spirometry is the gold standard and must be utilized to identify for primary care too Pulmonary function tests. I’d to be a provider purchase a chest x ray to eliminate another disease progression or maybe international body involvement (Gold, 2017) Exercise anxiety assessment might be also worn in diagnosing as well as figuring out severity. History of cough with improved sputum plus reduced exercise intolerance are symptoms of COPD (Gold, 2017). Please click the purchase button to access the entire copy at $5

 

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