CLINICAL SKILLS EVALUATION

PATIENT NOTE

HISTORY: Describe the history you just obtained from this patient. Include only information
(pertinent positives and negatives) relevant to this patient's problem(s).
Frank Emmanuel is a 32 yo M who came in for the evaluation of pre-employment work-up. He is a
known chronic smoker with 1ppdx 10 yrs. He emigrated from Africa a month ago, with no PPD test
done. No TB vaccine and Hep B vaccine remembered. Of note was a productive cough, with sputum
characterized as whitish, mucoid, 1/2 tbsp, non-blood tinged, and odorless, with no associated
symptoms such as DOB, PND, orthopnea, body weakness, and night sweats.
ROS: none except above
PMH: no HTN, DM, Cancer, Hepa, TB and HIV
Meds: none
All: NKA
PSHx: none
Immunizations: UTD vaccine record to be retrieved by patient
SH: coal miner for several years in his hometown, married to his wife; not using condoms; no STD,
1ppd smoker x 10 yrs, denies alcohol and drug use; not stressed

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's
problem(s). Be careful to include only those parts of examination you performed in this encounter.
VS: BP 130/85; T 98.3F (36.8C); R 15; HR 70
HEENT: clear oropharynx, neck supple without LAD and thyromegaly; no jaundice
Heart: RRR, S1/S2 intact, no m/r/g, no heaves and lifts
Lungs: no lagging, CTAB/L, no wheezes and crackles, negative whispered pectoriloquoy, negative
egophony; resonant
Ext: no clubbing, cyanosis and edema

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/ COPD

History Finding(s) Physical Exam Finding(s)

productive cough whitish sputum none
no night sweats
1ppd smoker x 10 yrs

Diagnosis #2: Pneumoconiosis

 History Finding(s) Physical Exam Finding(s)
coal miner none
productive cough whitish sputum
1ppd smoker x 10 yrs

Diagnosis #3: TB

History Finding(s) Physical Exam Finding(s)

emigration rom africa x 1month none
chronic cough x 4 years

Diagnostic Study/Studies
CBC with differentials
Sputum studies (AFS with sputum culture)
CXR
Low dose CT scan of the chest
TB screening (PPD, Interferon gamma
quantiferon)