Case Study

User Generated

zhebfb

Health Medical

Concorde Career College

Description

Alex is a 9 year old male brought in by Mom for a persistent cough x 1 month. No one else in the home has been sick. The cough is dry, waxes and wanes, but worse during PE and at night. Mom smokes outside of the house. He tells you that sometimes, it hurts to take a deep breath in and feels like it’s tight. Mom adamantly denies any rhinorrhea, nasal congestion, sore throat, otalgia, fevers, chills or malaise. Alex is otherwise UTD on routine childhood immunizations, was born FT and has no known PMH.Each group will be assigned a body system and the signs/symptoms presenting with that system. From this, each group member of the group will formulate at least one different, primary care differential diagnosis with lab and radiology (as applies) workup and plan for that differential. For the lab and radiology that you include, you will need to provide interpretation, to include what the high/low values are as well as common indications that occur with highs/lows. Your differential and diagnostic workup and treatment must be supported by peer-reviewed, recent references (no later than 2018) and resources pointing to best practices. There must be a minimum of three references per differential. All of this should be laid out in APA style and presented in a format of your choosing.

EXPECTATIONS:

1 Primary Diagnosis

3x Differential diagnosis

ppt presentation

Word document in APA 7th edition format

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Explanation & Answer

Attached.

1

Differential Diagnosis Case Study

Student's Name
Institutional Affiliation
Course Number
December 12, 2023

2
Differential Diagnosis Case Study
SUBJECTIVE
ID: Alex, a 9-year-old male, is brought in by his mom due to a persistent dry cough,
exacerbated during physical activity and at night, with occasional pain and tightness during
deep breaths.
CC: "Persistent cough and difficulty breathing."
HPI: Alex has been experiencing a persistent dry cough for the past month, exacerbated
during physical activity and at night. He reports occasional pain and tightness when taking
deep breaths. There is no history of recent illness in the household. Mom smokes outside. No
other respiratory symptoms reported. No known PMH. Immunizations up to date.
PMH:


Medical: None



Surgery: None



Preventive Care: Up to date on childhood immunizations



Allergies: None



Medications: None

Family History:


Maternal and paternal grandparents: Deceased (unknown medical history)



Mother (Alive): No significant medical history



Father (Alive): Hypertension (unknown)

Social History:

3


Marital Status: Single, not sexually active



Occupation: Full-time student (graduate school)



Living Arrangement: Lives in a house with parents



Diet: Balanced cooked meals, drinks 1L of water per day, 2 cans of energy drink/day



Exercise: Denies



ETOH/Vaping/Nicotine/Drugs: Denies



Stress/Sleep: Increased stress for the past week due to school requirements, sleeps
about 6 hours/day

ROS:


CONSTITUTIONAL: Denies fever, chills, nausea, vomiting



HEENT: Denies visual changes, ear pain/discharge, epistaxis, congestion, dysphagia



Neurological: Denies confusion, memory loss, aura; (+) headache: 2-10/10 throbbing
or pounding pain localized occipital area



Cardiovascular: Denies chest pain, palpitations, dyspnea on exertion



Pulmonary: Denies dyspnea, SOB, cough, wheezing



Psych: Denies anxiety, depression

OBJECTIVE
Vital Signs:


Temperature: 98.2 F (oral); Pulse: 85 bpm; Respiratory: 18 bpm; BP: 110/70 mmHg;
SPO2: 98% Room air

4
Physical Exam:


General Survey: Alert and oriented x4, appears well-nourished, no signs of distress



Respiratory: Mild intercostal retractions, occasional non-productive cough



Chest: Clear on auscultation, no wheezing



Cardiac: Regular rhythm, no murmu...

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