History:(Describe the history you just obtained from this patient.

Include only
information (pertinent positives and negatives) relevant to this patient's problem(s). )

HPI=65 yo M c/o of cough X 3 wks. It is ,getting worse,INTERMITTENT,HAS 2-4 X/D,EACH

LASTING 5 MINS,aggravated by exercise and lying flat at night,no alleviating factors. He also
hasHas yellowish sputum, 1 tea spoon phlegm with blood. No chest pain, heart racing, fever,
night sweat. No weight change, no appetite change. Recent travel history to Kenya. No ill
contact. No TB contact. No previous episode…..5 LINES
HPI…lung??cancer??gerd???PND???

Why belly Q in this????

ROS=no headache/eye problems/sore throat/abdominal pain, bowel movement changes or

urinary problems., there throat====OR==NEGATIVE Formatted: Highlight

PMH=HTN X5 YRS

PSH=gall bladder removal 5 yrs ago

Alls=penicillin, skin rash

MEds=atenorol atenolol

FH=brother died of lung cancer, father died of brain hemorrhage, mother died of heart failure

SH=works as a school teacher, 1PPDX10 yrs, no EtOH, no illicit drug

Sex=sexually active with 3 females without protection

Physical exam: Describe any positive and negative findings relevant to this patient's
problem(s). Be careful to include only those parts of examination you performed
inthis encounter.

Not in acute distress

VS WNL except BP 160/78

No cyanosis/clubbing, no pallor/ icterus

HEENT oral mucosa pink,moist, no LAD

Neck no JVD, no bruit

Chest =no scars/bruises/deformities,non tendern,tvf=nl,resonant b/l,CTAB, fremitus normal,

Heart RRR, S1/S2 WNL, no PMI displaced no M/G/R

Abdomen soft, not distended, no tender, no HSM

Ext no edema, no rash

DATA INTERPRETATION: Based on what you have learned from the history and the
physical examination, list up to 3 diagnoses that might explain this patient's
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 the 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: chronic bronchitis

History Finding(s) Physical Exam Finding(s)

yellowish, 1 tea spoon phlegm

1PPDX10 yrs

Diagnosis #2: lung cancer

History Finding(s) Physical Exam Finding(s)

yellowish, 1 tea spoon phlegm with blood.

Recent travel history to Kenya

1PPDX10 yrs

Diagnosis #3:tuberculosis

History Finding(s) Physical Exam Finding(s)

yellowish, 1 tea spoon phlegm with blood.

Recent travel history to Kenya

Work up

1 CBC with differential

2 Chest X ray

3 Sputum culture, gram stain

4 Sputum AFB

5 Quantiferron, TTB Formatted: Highlight

6 Chest CT

7 Bronchoscopy