11 May WHAT IS YOUR DIFFERENTIAL DIAGNOSIS LIST FOR THIS VISIT THUS FAR WITH RATIONALE?
You enter the room and introduce yourself. Sean is sitting in the chair texting on his cell phone. You ask what brings him in today. Sean smiles, shaking his head and says “My wife made me come, I feel fine.” Three days ago Sean felt short of breath, had this heavy feeling in his chest, and he got kind of nauseous and sweaty. It lasted only about 3 minutes, and it has not happened again, but he does feel a little more tired. “It could be that I have not worked out since it happened, and I have more energy when I walk on the treadmill.”
PMHx: Reports general health as good. Had been feeling great since starting to work out and lost weight. Had lots of energy and felt great until this episode 3 days ago. Now he is a little concerned because he feels a little more tired when he works out. He has not done as much strenuous running and shortened his workout since the episode.
Childhood/previous illnesses: chicken pox.
Chronic illnesses: Hypertension, Lisinopril stopped 3 months ago. Elevated cholesterol, lifestyle management was initiated.
Surgeries: T and A, cholecystectomy, vasectomy
Hospitalizations: None
Immunizations: Does not receive the flu shot.
Allergies: NKDA
Blood transfusions: None
Enjoys a beer or a glass of Jameson and the occasional cigar when playing poker with his buddies
Current medications: None
Social Hx: Married for 20 years, works as a mortgage broker at a local bank
Family Hx: Parents are deceased. Father had lung CA and mother died from complications of a stroke. Brother died at 44 from malignant melanoma. Other sister and brother are healthy.
Discussion Questions Part One:
What further questions do you have for Sean at this visit?
What is your differential diagnosis list for this visit thus far with rationale?
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