Today you are off from the clinic and are covering a shift in the emergency room

Today you are off from the clinic and are covering a shift
in the emergency room department. You go
to see Mr. ABC a 34-year-old Hispanic male who presented with a compliant of
severe dyspnea. He has been experiencing
dyspnea for 2 weeks that has slowly, but progressively gotten worse. He was brought back immediately from triage
because he has a respiratory rate of 40, an 02 sat of 88%, and a temperature of
101. His o2 sat has improved 92% on 4 Liters of oxygen via N.C. Rzeview of symptoms is positive for fever, chills,
weight loss, malaise/fatigue, diaphoresis, cough, dyspnea, weakness, swelling
in his lower extremities, feeling of abdominal fullness, and unintentional weight
loss. He denies any other symptoms. Past medical History includes Asthma. Past
surgical history, none. Social history,
single male, has sexual relations with men and women, denies smoking use. Has a history of iv drug use but has not used
for 5 years and used to be a heavy drinker for 10 years. He has not drank for 2 years.
Physical Exam
Vital signs temp 101,
heart rate 120, resp rate 38 blood pressure 110/60, o2 sat 92% on 4 liters N.C.
Constitutional: Alert and oriented x 3. Thin.
Head: Normocephalic and atraumatic
Eyes: Pupils are equal, round, and react to light. No
nystagmus. No scleral icterus.
Oropharynx: White patches on tongue and buccal mucosa
bilateral
Neck: neck supple. No JVD present. No tracheal deviation present.
No thyromegaly or thyroid nodules noted.
Cardiovascular :Normal rate, S1 normal, S2 present, without
S3, S4 gallop, friction rub or murmur. 1+ pitting edema to lower extremities.
Pulses: brachial, radial, dorsalis pedis, and posterior
tibial pulses are 2+/4+ bilaterally.
Pulmonary/chest: Dyspneic. Respirations regular and
even. Lungs have rales in all lung fields.
Abdominal: round, distended, soft. Bowel sounds are active. No mases noted. No CVA
tenderness. Hepatosplenomegaly present. Shifting dullness. There is no
rigidity, rebound, or guarding.
Lymph: has widely spread lymphadenopathy.
Neurological: Cranial Nerves II-XII intact.
Skin: skin is warm, dry and intact. A line of vesicles on the left thorax that
extends from the anterior to posterior thorax.
Psychiatric: mood and affect notrmal. Calm and cooperative
behavior. Judement intact.
MR. ABC’s Questions – Diagnosis is HIV/AIDS
Upon completing the history and physical Mr. ABC asks,you: “What
is wrong with me? Why am I sick? What do I need to do to get better? Your objective is to answer Mr. ABC’s
questions. To answer his questions
completely, you must integrate the answers to the questions below into your
response to Mr. ABC. Your response should
demonstrate that you are speaking with Mr. ABC as though you were in the room
with him.
1.
Based on the current information available, what
diagnosis do you believe Mr. ABC has? While your diagnosis still need to be
confirmed, you have enough information to know what is wrong with Mr. ABC.
2.
What labs and/or diagnostic tests do you believe
are needed to confirm your diagnosis?
3.
Describe the pathogenesis which explains the
patient’s condition?
4.
What education is important for Mr. ABC to receive?
Must use terminology appropriate for the target audience . all questions must be answered. WIll have to make a video so responses have to be less than 7 min in total

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