History Notecard by Jessica Szymanski

Case: Dylan Scott

Instructions: Use this worksheet to organize your thoughts before developing a differential diagnosis list.

1. Indicate Key Symptoms (Sx)

Identify key symptoms from the history. Start with the patient’s reason(s) for the encounter and add additional symptoms obtained from further questioning.

Reason for EncounterAdditional Symptoms

2. Characterize the Attributes of Each Symptom Using “OLDCARTS”

Capture the details in the appropriate column and row.

SymptomOnsetLocationDurationCharacteristicsAggravating FactorsRelieving FactorsTimingSeverity

3. Review Your Findings

Consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient’s age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case.

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This worksheet serves as a structured approach to collecting and analyzing patient history to aid in developing a differential diagnosis list.

History Notecard by Jessica Szymanski on Case Dylan Scott

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

1. Indicate key symptoms (Sx) you have identified from the history.

Start with the patient’s reason(s) for the encounter and add additional symptoms obtained from further questioning.

Symptom (Sx)Reason for EncounterAdditional Symptoms from QuestioningChief ComplaintShortness of breathAdditional SymptomsSwelling, cough, fatigue

2. Characterize the attributes of each symptom using “OLDCARTS”. Capture the details in the appropriate column and row.

Symptom (Sx)OnsetLocationDurationCharacteristicsAggravating FactorsRelieving FactorsTimingSeverityShortness of breath2 months agoChestOngoingWorse with activity and at rest, wakes up at nightActivity, laying on backNothingNone8/10Swelling2 months agoBilateral lower extremities, abdomenOngoingProgressively worseningUnknownNothingNone6/10Cough2 months agoChestOngoingWhite frothy phlegm, wheezingUnknownNothingNone7/10FatigueAfter onset of SOBGeneralizedOngoingFeeling of exhaustion, worse with exertionActivityRestNone6/10

3. Review your findings and consider possible diagnoses that may correlate with these symptoms.

Patient Details:

• Age: Consider the patient’s age
• Risk Factors: Relevant medical history, lifestyle, and environmental factors

Possible Diagnoses:

1. Congestive Heart Failure (CHF):
   • Symptoms: Shortness of breath, swelling, fatigue, cough with white frothy phlegm
   • Characteristics: Symptoms worse with activity, progressive swelling, and nighttime shortness of breath
   • Risk Factors: Hypertension, coronary artery disease, history of heart disease
2. Chronic Obstructive Pulmonary Disease (COPD):
   • Symptoms: Shortness of breath, cough with phlegm, wheezing
   • Characteristics: Symptoms exacerbated by activity and laying down
   • Risk Factors: Smoking history, exposure to lung irritants
3. Pulmonary Edema:
   • Symptoms: Shortness of breath, swelling, cough with frothy sputum
   • Characteristics: Worsening symptoms with activity, nighttime shortness of breath
   • Risk Factors: Heart conditions, renal failure
4. Pulmonary Hypertension:
   • Symptoms: Shortness of breath, fatigue, swelling
   • Characteristics: Progressive worsening of symptoms, difficulty breathing at night
   • Risk Factors: Chronic lung diseases, heart conditions
5. Asthma:
   • Symptoms: Shortness of breath, wheezing, cough
   • Characteristics: Symptoms triggered by activity and environmental factors
   • Risk Factors: Allergies, family history of asthma

Guidance for Physical Examination:

• Focus Areas: Cardiac and respiratory examination, check for peripheral edema, jugular venous distension, and auscultation for heart and lung sounds.
• Additional Tests: Chest X-ray, ECG, echocardiogram, pulmonary function tests, blood tests (BNP, CBC).

This structured approach will aid in organizing symptoms, correlating them with potential diagnoses, and planning the next steps for physical examination and diagnostic testing.