Case Study: Diagnosis of Respiratory Issues, Exams of Nursing

Download Case Study: Diagnosis of Respiratory Issues and more Exams Nursing in PDF only on Docsity! Case Study NURS 601 Week 2 part one Latest Update 2024. Download To pass Definite Success 1. BRIEFLY AND CONCISELY SUMMARIZE THE HISTORY AND PHYSICAL (H&P) FINDINGS AS IF YOU WERE PRESENTING IT TO YOUR PRECEPTOR USING THE PERTINENT FACTS FROM THE CASE. USE SHORTHAND WHERE POSSIBLE AND APPROVED MEDICAL ABBREVIATIONS. AVOID REDUNDANCY AND IRRELEVANT INFORMATION HPI Pt. is a 62-year-old male with a CC of persistence cough X 6 months and acute onset SOB. He describes the cough as intermittent but more frequent in the AM. He characterizes his cough as productive with white-yellow phlegm c/o. He identifies activity as an aggravating factor and has experienced some relief with rest but has tried Robitussin DM with no relief from symptoms. He denies chest pain, however he states that he has a decrease in activity tolerance in the last year stating that he isn’t able to go more than 20 feet without stopping for breath. Pertinent PMH He has a history of primary hypertension and takes 50mg metoprolol succinate ER daily along with a multivitamin. He is has an allergy to PNC accompanied by a rash. He has an hr of smoking cigarettes 20 packs a year when he quite “cold turkey” after the death of his father. No illicit drugs or alcohol use. He is married with 2 children and works as an accountant at a risk management firm. His family hr includes the death of his father at 59 due to CHF and MI. His father also suffered from diabetes, hypertension and smoking. His mother is still living and has osteoporosis and his siblings are living and healthy. Pertinent ROS findings: 1 The patient is + for persistent cough in AM x 6 months. + for productive whitish, yellow phlegm. +SOB with activity. He is - for fever, chills, or weight loss. He is also - for nostalgia, logorrhea, rhinorrhea, congestion, sneezing or PND. He is - for ST or redness, lymph node tenderness, or swelling, chest pain, or LE edema. Pertinent PE findings: Adult male, who is he is AAOx3, in NAD, + for complete sentences. Temp, RR, P are normal. Patient is + for Obesity with BMI of 39.24. +for elevated BP at 156/94. +norm cephalic. + patent nares, + clear nasal turbinate’s, +clear nasal drainage bilaterally, - redness, - edema, OP + moisture, - exudate or lesions. +tonsils at ¼, +normal dentation. Neck -for thyromegaly, lymphadenopathy, or masses, - JVD. Heart sounds with +S1 and S2, -murmurs. +clear lung sound bilaterally, -labored breathing. + faint forced expiratory wheezes bilaterally in the bases. – labored respirations. -for lower extremity edema bilaterally. Abdomen is + softness, -organomegaly, - abdominal tenderness. 2. PROVIDE A DIFFERENTIAL DIAGNOSIS (MINIMUM OF 3) WHICH MIGHT EXPLAIN THE PATIENT'S CHIEF COMPLAINT ALONG WITH A BRIEF STATEMENT OF PATHOPHYSIOLOGY FOR EACH. 2 3. ANALYZE THE DIFFERENTIAL BY USING THE PERTINENT FINDINGS FROM THE HISTORY AND PHYSICAL TO ARGUE FOR OR AGAINST A DIAGNOSIS. Diagnosis #1 – COPD The primary diagnosis I have chosen is COPD. The symptoms of COPD include shortness of breath, activity intolerance, chronic cough, clear or yellow tinged secretion with a previous history of smoking, exposure to noxious chemicals or fumes (Domino, Baldur, Golding, & Stephens, 2019). Other symptoms include decreased breath sounds, expiratory wheezes and prolonged expiration (Papadakos, McPhee, & Rambo, 2019). COPD is also seen in patients over the age of forty. Positive findings – He is positive for chronic cough x 6 months, with acute SOB with activity, progressive decline in activity tolerance, productive whitish/yellow sputum, history of smoking and 52 years old. He has tried OTC remedies for his cough that have not improved his condition (Domino et al., 2019). He is also positive for faint forced expiratory wheezes bilaterally in the bases of his lungs. Negative findings – He has no other signs or symptoms for a possible viral or bacterial infection as the cause of his productive cough (Domino et al., 2019). He is negative for boggy turbinate’s, abnormal nasal discharge bilaterally, or nasal redness or edema, fever or chills. He has no relief in his symptoms by using OTC cough suppressant (Hammer & McPhee, 2019). He is also negative for PND, nostalgia, logorrhea, rhinorrhea, congestion or sneezing. His lungs are clear bilaterally to auscultation and his O2 saturation at room air is within normal range (Domino et al., 2019). Diagnosis #2 Asthma with acute exacerbation The secondary diagnosis I have chosen is Asthma. While asthma is considered an obstructive airway disease, the major defining characteristic is that is typically immune mediated and doesn’t have a slow increase in progression when compared with COPD (Papadakos et al., 2019). Another defining difference is that it is typically triggered by pollen, cold, exercise or animal dander and is accompanied with chest tightness, pain or pressure and inspiratory and expiratory wheezes and normal respirations in between attacks (Papadakos et al., 2019). Positive findings – He has faint forced expiratory wheezes bilaterally in the bases with a productive cough and acute SOB with activity (Domino et al., 2019). Negative finding – He is negative for inspiratory wheezing, acute cough with return to normal breathing which is a common symptom of asthma (Papadakos et al., 2019). He is negative for allergy’s or previous diagnosis of asthma and his O2 saturation at room air is within normal range He is also negative for chest tightness or chest pain, he is a smoker, and he is over the age of 40 with a progressive decline in activity tolerance. The third diagnosis I chose for my differential is CHF. I chose this diagnosis due to his elevated blood pressure, productive cough and activity intolerance, all of which are symptoms of CHF (Domino et al., ,2019). Fluid in the lungs can cause a chronic cough in CHF as well as wheezing due to pulmonary edema (Papadakos et al., 2019). This diagnosis should be ruled out due to the potentially eminent danger that CHF can pose to any patient who is undiagnosed (Domino et al., 2019). Positive findings – He is positive for productive cough for 6 months with an acute decrease in activity intolerance. He is positive for forced expiratory wheezes and elevated blood pressure (Domino et al., 2019). Negative findings – He has normal S1 and S2 heart sounds, negative for lower extremity edema, and lungs are clear to auscultation, He also denies chest pain and his O2 saturation at room air is within normal range (Domino et al., 2019). 4. IDENTIFY ANY ADDITIONAL TESTS AND/OR PROCEDURES THAT YOU FEEL IS NECESSARY OR NEEDED TO HELP YOU NARROW YOUR DIFFERENTIAL. ALL TESTING DECISIONS MUST BE SUPPORTED WITH AN EBM ARGUMENT AS TO WHY IT IS NECESSARY OR PERTINENT IN THIS CASE. IF NO TESTING IS INDICATED OR NEEDED, YOU MUST ALSO SUPPORT THIS DECISION WITH EBM EVIDENCE. The most common testing to rule out COPD is called a pulmonary function test, or PFT’s. PFT’s measure the patients inspiratory and expiratory volume and lung capacity and can reliably determine the level of restriction for the patient. This is a non-invasive and accurate way to diagnose COPD and has been the gold standard for diagnosis based on evidence-based practice for many years (Domino et al., 2019). It is important however to note that PVT’s are not recommended during an acute exacerbation of bronchospasm as the amount of obstruction cannot be accurately measured during this time (Domino et al., 2019). The COPD is staged as mild when the forced expiratory volume (FEV1) is less than 80%. If FEV1 is between 80-50% COPD is staged and moderate and less than 50% is considered the severe stage of COPD (Papadakos et al., 2019).