Clinical Presentation History: A 79 year old male presents to the emergency room complaining of shortness of breath and respiratory distress. The patient states they have no past medical history other than 15 years of chronic shortness of breath, due to not having seen a physician in the last 20 years. The patient states today is worse than it has ever been. The patient denies any specific pain, denies any recent trauma, and describes the onset of this episode as being gradual.

Vital Signs Heart Rate: 75 beats per minute. Blood Pressure: 140/90 mmHg sitting in tripod position. Temperature: 98.6 degrees Fahrenheit. Respirations: 25 per minute. Pulse Oximetry: 71% on room air. Mental Status: Alert & Oriented to person, place, events, but not time. 15/15 on Glasgow coma scale. Physical Examination Overall, the patient’s skin is pale, cool, and moderately diaphoretic. The patient is generally weak. Head/Ears/Eyes/Throat: Pupils are equal, round, reactive to light. Atraumatic, afebrile. No tracheal deviation. No jugular vein distention. Patent airway. Thorax: Lungs sounds clear and equal chest rise bilaterally with marked accessory assistance of intercostals in (respiratory) inspiration. Tachypneic at a rate of 25 respirations/min. Otherwise unremarkable physically. Abdomen: Some diaphragmatic breathing noted. No pain on palpation. No obvious distention, physically otherwise unremarkable. Pelvis: Stable and weight bearing, atraumatic and unremarkable. GI/GU: Patient reports irregular nocturia that is normal for him, normal bowel movements and no urine output today. Lab Values EKG and blood work over next 2 pages.

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Clinical Presentation History Instructions:

You may use a group of up to 4 total students to work through the study, however each student must submit their own unique write-up. You are welcome to use outside healthcare providers for help. Reference any major sources in the format of your choosing. Finally, in 5-6 paragraphs, explain the following:

• Working diagnosis, using a rationale to include differential diagnosis

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• Review of any significant clinical findings (labs, EKG’s, etc.) to support diagnosis

• Disease etiology

• Possible treatment plan to include any immediate interventions to establish a longterm plan

• Patient prognosis