ASSESSMENT 6 HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 29 YO M C/O RECENT MVA. PATIENT REPORTS DIFFICULTY BREATHING AND ABDOMINAL PAIN ON LUQ 8/10 INTENSITY. AGGRAVATED BY DEEP BREATHING AND MOVEMENT. NO ALLEVIATING FACTORS. COUGH PRODUCTIVE OF YELLOW SPUTUM NO BLOOD, NO OTHER DISCHARGE FOR THREE DAYS. FEELS HOT, PAIN IN HIS JOINTS AND PRESENTS WITH SOME SCRAPES AND BRUISES. RECENT MVA WITHIN 24 HOURS, DENIES ALCOHOL INVOLVEMENT, LAST NIGHT PATIENT HIT A POLE, DID NOT SEEK EMERGENCY CARE. WAS WEARING HIS SEAT BELT, DENIES HEADACHE, DIZZINESS, CHEST PAIN, HEAD TRAUMA, LOC OR CONVULSIONS. LAST MEAL WAS BREAKFAST 3 HOURS AGO WITH COFFEE. ROS:NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: NONE MEDICATIONS: NONE PMH: HAD A FLU A WEEK AGO PSH: NONE FSH: PARENTS ARE ALIVE AND WELL SH: DENIES TOBACCO, ETOH ON WEEKENDS, DENIES DRUG USE. WORKS AS A CASHIER. LIVES WITH GIRL FRIEND OF TWO YEARS. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. THE PATIENT IS IN ACUTE DISTRESS WITH DIFFICULTY BREATHING AND FATIGUED. THE TEMP IS 101.0 AND OTHER VITALS ARE WITHIN NORMAL LIMITS. HIS HEAD APPEARS NORMOCEPHALIC AND ATRAUMATIC. HIS NECK IS SUPPLE WITH NO LYMPHADENOPATHY. HIS BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HIS HEART SOUNDS ARE NORMAL S1/S2. HIS ABDOMEN IS TENDER IN THE LUQ, NONDISTENDED AND BOWEL SOUNDS ARE PRESENT.WAS NOT ABLE TO CHECK FOR SPLENOMEGALY DUE TO PAIN. THERE IS NO CVA TENDERNESS PRESENT. HE IS ORIENTED TO PERSON, PLACE AND TIME ON NEUROLOGICAL EXAM. HIS CN 2-12 ARE INTACT AND MOTOR STRENGTH IS 5/5 THROUGHOUT. THERE ARE NO BRUISES OR LACERATIONS ON SKIN EXAMINATION. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.

Diagnosis #1: PNEUMOTHORAX HISTORY FINDING(S) -RECENT MVA -DIFFICULTY BREATHING -ABDOMEN PAIN LUQ Diagnosis #2: HEMOTHORAX HISTORY FINDING(S) -RECENT MVA -DIFFICULTY BREATHING -ABDOMEN PAIN LUQ Diagnosis #3: RIB FRACTURE HISTORY FINDING(S) -RECENT MVA -ABDOMEN PAIN LUQ -DIFFICULTY BREATHING Diagnostic Studies: -CXR -XR/CT-ABDOMEN -PULSE OXIMETRY -URINE TOXICOLOGY -BLOOD ALCOHOL LEVEL

PHYSICAL EXAM FINDING(S) -PATIENT IS IN ACUTE DISTRESS -DIFFICULTY BREATHING -FATIGUED AND TEMP 101.0

PHYSICAL EXAM FINDING(S) -PATIENT IS IN ACUTE DISTRESS -DIFFICULTY BREATHING -FATIGUED AND TEMP 101.0

PHYSICAL EXAM FINDING(S) -PATIENT IS IN ACUTE DISTRESS -DIFFICULTY BREATHING -FATIGUED AND TEMP 101.0