Question

PBL CASE // 1
TRIGGER: Mr Bekele, a 45 years male farmer from machakel woreda comes to the hospital with a complain of cough and chest pain.
Discussion questions
1. Name the current problems of the patient
2. Write your assessment based on the patient presentation
4. To reach to ur initial assessment what history taking,
3. Identify the patient risk factors for the initial assessment
HPI: This is a 45 years male who was relatively healthy 1 weeks back at which time he gradually started to develop productive cough. He also has low grade fever, generalized headache, difficulty of breathing, loss of appetite, chest pain, and body weakness. He has no history of weezing, palpitation, body swelling, and vomiting.he has no history of allergy and family history of bronchial asthma and TB.
History of Past Illness: he has no previous history of hospitalization and had not taken any medication Personal and social history: he usually drink local alcoholic drinks like tela, areke.... He has seven family member with poor housing condition and uses spring water and has no pit latrine.
Review of system
General overview: weakness
HEENT: Headache
Respiratory: complain cough, and chest pain
CVS: No palpitation and poor exercise tolerance
GI: Has no NVD and abdominal pain
Endocrine: No hot and cold intolerance
GUS: No urgency, frequency and burning sensation during urination
MSS: No joint pain
Neuro: No seizure
Discussion question
How can you re arrange your assessments based on the above findings

To reach to your initial assessment what physical examination should be done?

What additional data would you need to approve your assessment

Answer 1

Based on the case study provided about Mr. Bekele, here are the responses to the discussion questions:

### 1. Name the Current Problems of the Patient
- **Cough:** Productive cough that has developed over the last week.
- **Chest Pain:** Associated with respiratory symptoms.
- **Difficulty of Breathing:** Indicating possible respiratory compromise.
- **Low-Grade Fever:** Suggestive of an infectious process.
- **Generalized Headache:** Could be related to fever or systemic illness.
- **Loss of Appetite:** As a result of systemic infection or discomfort.
- **Body Weakness:** Indicative of overall illness or potential dehydration.

### 2. Write Your Assessment Based on the Patient Presentation
- Based on the provided symptoms, Mr. Bekele likely has an infectious respiratory condition, such as pneumonia or bronchitis, potentially compounded by his living conditions (poor housing, lack of sanitation, and use of spring water). The presence of a cough with sputum production and chest pain raises concern for possible bacterial or viral pneumonia. The low-grade fever strengthens the suspicion of an infectious process. The body weakness and loss of appetite could indicate a systemic response to infection.

### 3. Identify the Patient Risk Factors for the Initial Assessment
- **Living Conditions:** Poor housing that may increase exposure to respiratory pathogens and contribute to overall health problems.
- **Water Source:** Use of spring water may pose a risk for gastrointestinal or respiratory infections if contaminated.
- **Alcohol Consumption:** Regular consumption of local alcoholic drinks may affect overall health, immune status, and could lead to malnutrition.
- **Family History:** Although no direct family history of bronchial asthma or TB was noted, the population may have shared environmental exposures.

### 4. To Reach Your Initial Assessment, What History Taking Should Be Done?
- **Duration and Characteristics of Cough:** Inquire about the type of sputum (color, consistency).
- **Associated Symptoms:** Clarify the severity and duration of difficulty breathing, chest pain, fever, and headache.
- **Exposure History:** Any recent sick contacts, travel history, or exposure to other respiratory infections.
- **Previous Respiratory Issues:** Inquiry into any past episodes of lung infections or chronic respiratory issues.
- **Social Determinants of Health:** Details on housing conditions, access to healthcare, and socioeconomic background.
- **Substance Use:** Determine frequency and quantity of alcohol consumption and any tobacco use.
- **Nutritional Status:** Assess diet and overall nutrition.

### 5. What Additional Data Would You Need to Approve Your Assessment?
- **Physical Examination Findings:** Including vital signs (temperature, respiratory rate, heart rate, blood pressure), lung auscultation (for rales, wheezes, or dullness), and general appearance.
- **Laboratory Tests:** CBC (complete blood count) to assess for leukocytosis or anemia, sputum culture, and sensitivity.
- **Imaging Studies:** A chest X-ray to evaluate for pneumonia, pleural effusion, or other pathology.
- **Pulmonary Function Tests:** If asthma or COPD is suspected later on.
- **Microbiological Testing:** Consider testing for TB if clinically indicated, especially given the poor living conditions.
- **Hydration Status:** Evaluation for signs of dehydration due to illness.

### Re-arranging Assessments Based on Findings
- It is important to prioritize assessments based on the severity and potential implications. Start with:
1. **Vital Signs:** To determine respiratory distress, fever, and overall stability.
2. **Physical Examination:** Focus on the respiratory system, including auscultation, palpation, and checking for cyanosis or accessory muscle use.
3. **Laboratory Tests and Imaging:** This should follow physical examination to confirm the assessment and guide treatment.

Addressing these assessments timely is crucial for management and treatment planning.