his week, complete the Aquifer case titled “Family Medicine 28: 58-year-old man with shortness of breath”
Apply information from the Aquifer Case Study to answer the following discussion questions:
- Discuss the Mr. Barley’s history that would be pertinent to his respiratory problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
- Describe the physical exam and diagnostic tools to be used for Mr. Barley. Are there any additional you would have liked to be included that were not?
- What plan of care will Mr. Barley be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
While working with your family medicine preceptor you are scheduled to see Mr. John Barley, a 58-year-old man who has sought medical attention only rarely in the past 10 years. He comes to the office today because of progressively worsening cough and shortness of breath during the previous month.
Before you and your preceptor Dr. Wilson enter the room to meet Mr. Barley, you think about the definition of dyspnea:
Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.
You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you.” Mr. Barley says, “Sure, anyone working with Dr. Wilson is OK by me.”
You learn that he has not traveled recently, which could have exposed him to an unusual form of pneumonia. He also has not been exposed to tuberculosis. From other questions, you learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). You know that he has had no orthopnea.
As a farmer, he is active during the day. Deconditioning is not likely.
Wondering if his shortness of breath is due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes.
You say, “So I understand that you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes.”
“Let’s go in and do the physical together,” says Dr. Wilson, “But, first, what are you thinking so far, in terms of a differential?”
After pausing to think, you reply to Dr. Wilson, “He could have bronchitis.”
“Good thought.” Dr. Wilson added, “What in the history supports bronchitis?”
You reply that the cough and shortness of breath of two to three weeks duration could support acute bronchitis.
Dr. Wilson tells you, “While the duration of illness provides a clinical distinction between acute and chronic bronchitis, the actual mechanisms and pathophysiology also probably differ between the two. Chronic bronchitis causes long-term inflammation that can lead to irreversible structural changes. He might qualify for this diagnosis because he describes cough with phlegm production during the past two winters. But let’s assume for the moment that he doesn’t have chronic bronchitis.”
He then prompts you, “What else are you thinking for the differential diagnosis?”
After knocking on the door to make sure Mr. Barley is ready you and Dr. Wilson enter the room.
You say to Mr. Barley, “I’m going to do the physical exam, and then Dr. Wilson will repeat it.” He nods assent.
Your exam reveals:
Temperature: 98.9 Fahrenheit
Heart rate: 94 beats/minute
Respiratory rate: 22 breaths/minute
Blood pressure: 128/78 mmHg
General: Appears mildly short of breath
Head, eyes, ears, nose and throat (HEENT): Normocephalic / atraumatic, conjunctivae and sclerae are normal, PERRL, oropharynx is normal.
Neck: Supple without masses, lymphadenopathy, or thyromegaly. Laryngeal height measures 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration.
Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely.
Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border (RUSB) with radiation to the left lower sternal border (LLSB).
Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness.
Extremities: 1+ pitting pretibial edema.