INTERNAL MEDICINE

CASE 1 – DAY 1

HISTORY AND PE

A 78-year old male consults for worsening of productive cough and dyspnea over 3
days.
He is hypertensive for 10 years with good compliance to Losartan 50 mg OD (usual BP
110-120/70-80 mmHg). He is a former smoker of 80 pack years and quit 10 years ago. He uses
biomass fuel for cooking. He previously completed treatment for PTB 15 years prior.
For the past 6 years, he had intermittent cough productive of minimal white sputum. This
was followed with slowly progressive exertional dyspnea. He has visited the emergency room
for shortness of breath for which he was prescribed antibiotics and steroids 6x in the past 3
years. This year he usually needs to stop to catch his breath while walking on a level plane and
his legs have become swollen. He has lost weight of approximately 5 kg in the past 6 years.
Three days prior to consult, he developed fever and coryza. His cough worsened and his
sputum became purulent. His dyspnea acutely worsened, now with associated chest tightness,
precluding him from doing his daily activities.

General survey:
Patient is awake, coherent, oriented tachypneic and speaks in words
BP 150/80 mmHg RR 35/min HR 155/min Temp 39 C Wt. 50 kg Ht 160 cm
SpO2: 87% room air
Neck: no lymphadenopathies, prominent sternocleidomastoid muscles with supraclavicular and
suprasternal retractions
Chest and Lungs: widened intercostal spaces, with accentuated intercostal retractions, equal
tactile fremitus, equal vocal resonance, hyperresonance on percussion, decreased air entry ,
crackles right base with distant diffuse sibilant wheezes bilaterally
CVS: distinct heart sounds, tachycardic, regular rhythm, no murmurs
Abdomen: scaphoid, thoracoabdominal paradox, normoactive bowel sounds, soft, non tender,
no palpable masses, + hepatojugular reflux
Extremities: strong pulses, grade 2 bipedal pitting edema
QUESTION #1
Give 5 differential Diagnoses and the bases for your consideration
ANSWERS:

DIAGNOSES BASIS SCORE

QUESTION #2
What 5 priority diagnostics will you request for this patient? Give your bases for the
chosen diagnostics.
ANSWERS:

DIAGNOSTICS BASIS

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