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A 35 year old man patient who identified as a male. He presents to Neosho Regional Medical Center with c/o chest pain, fever, chills and difficulty breathing. Patient also has a history of diabetes and thyroid issues.

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Patient has been running a fever for over a week as high as 103.1, difficulty breathing started about 2 days ago.

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A 35-year-old men who identifies as male. He presents to Neosho regional medical center with a C/O chest, pain, fever, chills and difficulty breathing. Patient also has a history of diabetes and thyroid issues.

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A 35-year-old men who identifies as male. He presents to Neosho regional medical center with a C/O chest, pain, fever, chills and difficulty breathing. Patient also has a history of diabetes and thyroid issues.

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How to Participate: Each student enrolled in the course will be responsible to add an element to the patient's developing medical record.

Create a post to build on to your classes original patient case study.

1. The first student posting will add on to the initial post with the "Patient Demographics and Chief Complaint" section.

2. Each subsequent student should add ONE new detail to build the patient’s medical history.

1. You may choose to post your detail in any of the remaining categories - History of Present Illness, Past Medical History, Physical Exam, or Treatment/Plan (may need to scroll across the page).

3. Review previous posts to ensure your addition maintains consistency with the developing case.

4. Add your detail in the appropriate section based on the type of patient and unfolding details. For example, you would not add details like a male patient, presents to the oncology unit, for routine OB check.

5. Click the (+) to add your post

Note : Ensure all information added would reasonably develop into a patient case study that is not too generalized. You do not want this patient's medical record so limiting that it is boring, but not so narrow that it's hard for other students to add additional details.

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(The first student will address where the patient presented to and for what reason, the remaining students will add details under the headings provided, by clicking (+) under the header.)

This scenario begins with a 35-year-old male patient who identifies as male. He presents to:

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The patient’s past medical history includes the chronic conditions of:

-Diabetes Mellitus

-Hypothyroidism

-Congestive Heart Failure

-Pulmonary Edema

Significant events and/or procedures include:

-Myocardial Infarction, three years ago

-Appendectomy, seven years ago

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1. Check vital signs:

° Temperature, HR, RR, SpO2, and BP - assess for tachycardia, tachypnea, hypotension, or hypoxia.

° Pain characteristics- location, radiation, quality, triggers, and relief.

2. General appearance:

° Look for signs of sepsis (altered mental status, diaphoresis, pallor, cyanosis).

3. Cardiovascular Exam:

° Heart rate, rhythm, and regularity.

° Check for murmurs, gallons, or rubs (suggestive of pericarditis or valvular disease).

° Peripheral pulses and capillary refill.

1. Next steps (if any things seem off or may apply)

° immediate tests: EGG, chest X-ray, blood culture's, CBC, CRP, troponin, D-dimer, arterial blood gases if hypoxia is present.

° Oxygen therapy: if SpO2 < 92% on room air.

° IV access: for possible antibiotics or vasopressors if sepsis is suspected.

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Patient has been running a fever for over a week as high as 103.1, difficulty breathing starting about 2 days ago.

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Patient has been running a fever for over a week as high as 103.1, difficulty breathing starting about 2 days ago.

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Patient has been running a fever for a week as high as 103.1, difficult to breathing started about 2 days ago.

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Patient has been running a fever for a week as high as 103.1, difficult to breathing started about 2 days ago.

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blood work comes back negative for sepsis but treating with IV antibiotics for pneumonia. Presented difficult breathing and high fever. Chest xray shows clouding around the lungs. Watching Oxygen levels on room air every 4 hours along with vitals

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Patient reports a dry, persistent cough that started about three days ago and has been getting worse.

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A 35-year-old male patient who identifies as male.  He presents to Neosho Regional Medical Center with c/o chest pain,fever, chills and difficulty breathing. Patient also has a history of diabetes and thyroid issues.

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A 35-year-old male patient who identifies as male.  He presents to Neosho Regional Medical Center with c/o chest pain,fever, chills and difficulty breathing. Patient also has a history of diabetes and thyroid issues.

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Plan at this time is to admit patient. Lab work will be drawn in the morning to check CBC, breathing treatments will be given every four hours by respiratory therapy. Continue IV antibiotics at least 48 hours. Depending on lab work and o2 we will revisit discharge criteria when IV antibiotics are finished in 48 hours.