aquifer case study
Case Analysis Tool Worksheet
Student’s Name: Case ID:
I. Epidemiology/Patient Profile
Mr. Dennision is a 40-year-old, male, non-smoker with a history of allergic rhinitis.
II. Prioritized Cues from Hx and PE.(Do not include lab, x-¬‐ray, or other diagnostic test results here.)
• Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.
• Tier 2: These are cues of intermediate importance (list only positive cues).
• Tier 3: Of least importance (list only positive cues).
Tier 1 Tier 2 Tier 3
Productive cough with clear sputum for 2 months BMI-Overweight Lives with his wife and 2 children who are healthy
Cough is worse at night (2 nights/week) Afebrile Able to jogs and rides bicycle without problems with breathing.
Wheezing present Denies chest tightness/pain
Swelling of inferior turbinates
Pallor of the nasal mucosa with clear drainage
Family history of allergic rhinitis and asthma (father)
Occasional intake of aspirin
Sneezing and nasal congestion x3-4 mos, occasional light yellow tinge drainage
Non-adherence to medication such as cetirizine and allergy shots
III. Problem Statement
Mr. Dennison is a 40-year-old, non-smoker, non-alcoholic, overweight male patient who presented with nagging cough accompanied by clear sputum for 2 months, associated with wheezing which bothers him at night about 1 to 2 night/week. Patient also denies fever. He also reported that he feels better during the day without wheezing and cough when he jogs or rides a bicycle. He admitted of occasional aspirin intake without problem. Patient has a history of allergic rhinitis and his deceased father has a history of allergic rhinitis and asthma. Reports of sneezing and nasal congestion for 3-4 months with occasional light yellow tinge drainage and non-adherence to cetirizine and allergy shots for his allergic rhinitis.
IV. Differential Diagnosis
Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s).
List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.
Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis.
Leading dx:
Moderate persistent asthma with uncontrolled allergic rhinitis and possible chronic sinusitis
History Finding(s) Physical Exam Finding(s)
Overweight Swollen inferior turbinates
History of allergic rhinitis Pale nasal mucosa with clear drainage
Occasional aspirin intake Normal symmetrical expansion of the lungs
Productive cough with clear drainage x2 mos All lung fields are clear to auscultate
Associated with wheezing
Family history of allergic rhinitis and asthma
Sneezing and nasal congestion x3-4 mos, occasional light yellow tinge drainage
Non-adherence to medication such as cetirizine and allergy shots
Alternative dx:
Chronic Obstructive Pulmonary Disease
History Finding(s) Physical Exam Finding(s)
Productive cough for 2 months Swollen inferior turbinates
Wheezing presents at night Pale nasal mucosa with clear drainage
Overweight
Alternative dx:
Nonasthmatic Eosinophilic Bronchitis
History Finding(s) Physical Exam Finding(s)
Productive cough for 2 months Swollen inferior turbinates
Wheezing presents at night Pale nasal mucosa with clear drainage
Sneezing and nasal congestion x3-4 mos, occasional light yellow tinge drainage
V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
Spirometry both with and without bronchodilators Measures how much air the patient can inhale and exhale
CT Scan Investigates if the patient has chronic sinus infection
Treatment Plan Rationale
Lifestyle Modification Avoiding irritants and diseases that can trigger his asthma attack such as allergic rhinitis
Offer Asthma Medications Combination of ICS and LABA + SABA as needed to prevent asthma attacks
Offer medication for allergic rhinitis (Cetirizine pills) To prevent allergic rhinitis that can trigger asthma
Give Asthma Plan Aids in managing his asthma
Educate on how to use peak flow meter, MDI/inhalers Helps in managing asthma and when to get emergency in case the patient has flare-up.
Review Immunizations To prevent patient from getting flu and pneumonia that can also trigger asthma
Weight management (diet and exercise) Helps in improving asthma control.
Reports signs and symptoms of sinusitis To avoid trigger that may worsen the asthma.
I have adhered to the honor system:
Student’s signature