In this case you will meet Mr. John who came in because of dyspnea times 2 days. The vital signs are T= 98.4 P= 98 RR=22 BP=156/95 weight of 290. Your job is to illicit the history and do an examination. Write out your differential diagnosis, work up and treatment plans. You have 15 minutes to interview and 15 minutes to write. Begin.

knock, knock, this is Dr. Smith, may I come in.

Yes, doctor.

Hi Mr. John, I am doctor Smith. Nice to meet you.

Same here.

Mr. John, what brought you in today?

Dr. I have a terrible short of breath. I can't even walk from my room to the kitchen.

How long has this been going on?

It has been going on for 2 days and it is getting progressively worse. At first I was able to go to the kitchen to open the refrigerator and get something to eat... I love to eat, you know. Some people called me "piggy"

That is not very nice for people to call you piggy. Tell me what is your baseline activity like... like how far can you walk before you have short of breath?

Well, I usually can walk one to two blocks without getting short of breath. But just recently I have a cough and everything went down hill.

When did you have the cold or cough?

Just 2 days ago.

Did you have fever or chills?

No.

Did you cough anything up?

Greenish sputum.

Any sick contact at home.

Yes, my wife is sick with a flu.

Have you been eating a lot of salty food. Have you dined out a lot recently?

Yes, my doctor told me to watch my salt intake, but recently I went to Disney and I love those turkey legs so I ate 5 of them and I dipped them in salt.

How many pillows do you have to sleep on?

I used to be able to sleep on 4 pillows. Now I have to sit up to be able to go to sleep.

Do you have to wake up in the middle of the night to gasp for air?

Yes, it is getting worse recently.

Do you have increase in swelling?

Yes, my legs swell up like a potato.

I am going to ask you different questions that may not related to your complaint so bear with me okay. Just to make sure we are not missing anything.

Do you have headache? Do you have blurry vision? Do you have nausea or vomiting? Do you have chest pain? Do you have diarrhea or constipation? Do you have problems with burning on urination? Do you have pain on walking? Do you have problems with erectile dysfunction?

No, to everything except for erectile dysfunction and pain on walking.

Thank you. Do you have any other past medical history?

Yes, I have high blood pressure, dyslipidemai, and a slight touch of COPD.

When was the high blood pressure diagnosed?

It was ten years ago.

What medications are you on now?

I am taking Lipitor 10 mg once a day for my dyslipidemia, and I am taking Hydrochlothiazide 25 mg once a day for my high blood pressure. I am also taking enalapril 40 mg once a day and metoprolol 100 mg twice a day for my blood pressure. For my COPD, I am taking combivent 2 puffs 4 times a day as needed.

Are you on oxygen at home for your COPD?
No.

Have you have a flu shot yet?

Not yet.

We will give that to you since you are high risk for getting a flu with your medical condition.

OK.

Have you ever had an echo of your heart?
No.

Do you have any surgeries?

No.

Does your mom, dad and siblings have any problems with diabetes, heart, or cancer?

My mom has high blood pressure. My dad died of a heart attack.

When did your dad die of a hear attack?

When he was 40.

Do you smoke?

Yes, I smoke 1 pack per day for 20 years.

Do you drink?

Occasionally, like once a month...just a beer or two.

Have you ever used IV drugs?

No, I do not toucht hat stuff. No cocaine, marijuana no no no...

Have you ever had blood transfusion?

No.

Are you allergic to anything?

No.

OK, I am done asking questions. Can I do a physical exam.

Sure, go ahead.

Generally- he is an morbidly obese male.
HEENT- jugular venous distention noted, neck supple, moist mucous membrane, nasal septum midline, no thyromegaly, pupil equal round and reactive to light and accomodation.
CV: regular rate and rythm. S3 noted over the apex. Point of maximal impulse is at the 6 intercostal space and deviated laterally.
Res: Crackles heard bilaterally up to his mid lung field, good air movement.
Abd: obese, no organomegaly, no masses, no ascites, bowel sound is normal active
Extremities: +3 pittting edema up to his knee. faint pulse PD and TB +1; moving all extremities well
Neuro: Cranial nerve II to XII intact. No focal deficits

OK, Mr. John. Thank you for letting me examine you. I think you have exacerbation of congestive heart failure. We will admit you to telemetry floor and start to diurese you. We will also want to check to make sure you don't have a heart attack so we will check cardiac enzymes during the night about every eight hours. We also want to make sure you don't have a pulmonary embolus, a clot to your lungs, that cause the shortness of breath so we will obtain a CT of your lungs. I will be up all night. So if you have any questions just ask the nurse to page me. Do you have any questions?

No. Thank you doctor.

Differential diagnosis:
Congestive Heart Failure
COPD exacerbation
Myocardial infarction
Acute Respiratory Distress Syndrome
Altitude Illness - Pulmonary Syndromes
Anaphylaxis
Anemia, Acute
Bronchitis
Chronic Obstructive Pulmonary Disease and Emphysema
Dysbarism
Hyperventilation Syndrome
Myopathies
Pericarditis and Cardiac Tamponade
Pneumonia, Aspiration
Pneumonia, Bacterial
Pneumonia, Immunocompromised
Pneumonia, Mycoplasma
Pneumonia, Viral
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Pulmonary Embolism
Shock, Septic
Venous Air Embolism

Workup:
BNP: Beta Natriuretic Peptide
Chest X-***
3 sets of Troponin I/ CPK/ EKG every 8 hours
2D-echo to evaluate systolic dysfunction
CBC
Complete metabolic profile
CTA to rule out pulmonary embolus
Consult pulmonary for sleep apnea studies
Pulmonary function test to stage his COPD

Initial Management:
Admit ot telemetry
2 grams low salt low cholesterol diet
Aspirin 325 mg 1 po QD
Morphine sulfate 1mg IV Q 4 hours.
Call MD for chest pain
2 liters of oxygen via nasal canula to keep sat greater than 92%
1 inch nitropaste to chestwall every 6 hours
Enalapril 40 mg 1 po QD
Hold metoprolol
Lasix 40 mg IV q8 hours
Strict In and Out
Daily Weights
Obtain old records to the floor
Out of bed with assist
Duonebs Q4 hours.