Please write a 1-2 paragraph response to each of these. Please include one reference for each response
CASE STUDY 1 – RESPONSE
Mason is a 55-year-old homeless man who you are seeing today for the first time. He is a smoker and states that he has frequent colds and a routine morning cough. He used to be short of breath just walking up hills, but he now has difficulty breathing with everyday activities and is having trouble finding food because he cannot walk very far. He just wants medicine to help him survive on the streets. On examination, you find him using his accessory muscles to breathe. His vital signs are 99°, 100 beats per minute, 28 respirations/min., and blood pressure 140/90. Breath sounds are distant with end-expiratory wheezes. He has a slight barrel chest and neck vein distention.
Demographics: 55 year-old male
SUBJECTIVE
- CC: Shortness of breath
- HPI: Shortness of breath with exertion
- Subjective:
- Interview questions:
- Constitutional:
- Are you able to eat 3 meals per day?
- Respiratory:
- Have you had a cough or recent cold?
- Do you have a history of asthma?
- How many cigarettes do you smoke each day? For how many years?
- What distance can you walk/how many staircases can you climb before you start feeling short of breath?
- Do you feel chest tightness?
- Do you have a history of heart problems, lung problems, or anemia?
- Do you have any numbness or tingling in your body? Where?
- What activities are associated with shortness of breath?
- Have you noticed phlegm when you cough?
- Do you have any known allergies ?
- Is there anything you can do to help yourself feel less short of breath, such as sit up, stay indoors, lie down, or use medication?
- Cardiac
- Have you noticed swelling in your legs?
Review of system:
Constitutional: Reports some fatigue. Concerns over obtaining necessary food. Denies night sweats, fever, chills nor weight changes
Respiratory: 30 pack-year. Reports shortness of breath, dry cough in morning, frequent colds. Denies dyspnea, wheezing, hospitalization,
Cardiovascular: Denies chest pain, dizziness or palpitation.
OBJECTIVE
General:
- VS BP 140/90, HR 100 BPM, RR 28, Temperature 99ºF, Weight 180, Pulsox: 94 % RA, Pain 0/10; Height 6’0, BMI 24.4.
- Physical Exam Elements:
- Respiratory: Productive cough. Labored breathing. Accessory muscle use. Slight barrel chest. Distant breath sounds with end-expiratory wheezes auscultated.
- Cardiac: Jugular vein distention. Finger nail clubbing. S1-S2 auscultated.
- Integumentary: Skin is pink consistent with race.
- POC Testing: Pulmonary function test, exercise oximetry.
ASSESSMENT
- Working Diagnosis: Emphysema J43
- Differential Diagnosis: Asthma J45.909, cor pulmonale I27.81, congestive heart failure I50.9, chronic bronchitis J42
PLAN
- Diagnostic studies: Imaging: Chest x-ray, Lab work: ABG, CBC, ESR
- Treatment:
Albuterol inhaler 90 mcg, 2 puffs as needed, every 4-6 hours. 10 refills
Tiotropium 1.25 mcg inhaler, 2 puffs per day. 10 refills
Nicotine gums 4 mg, 1 gum by mouth every 1-2 hours up to 9 times a day for 6 weeks #378. No refills.
- Referrals: Pulmonologist, social services.
- Education: Albuterol may speed up heart beat. Use a mask when around sick people, eat sufficiently, and avoid exposure to irritants. Use gum when a smoking urge occurs. Avoid eating or drinking 30 minutes before and while chewing nicotine gums, chew until gum is soft then park on the cheek.
- Health maintenance: Pneumococcal vaccine PVC13, influenza vaccine, COVID-19 vaccine, Mantoux test.
- RTC: Follow up in a month. Call or return if symptoms persist or worsen.
CASE STUDY 2 – REPSONSE
Jim is a 69-year-old male who comes in today complaining of dyspnea on exertion, and you have noted that he has gained about 25 pounds since his last visit 7 months ago. He tells you that he is not sleeping at night because of a constant cough, and he thinks he has a cold because he is coughing up pink frothy “spit”. He is extremely fatigued because of his lack of sleep. Your examination reveals bilateral 3+ pitting edema with his lower extremities being cool to the touch, distended abdomen, hepatomegaly, hacking cough, and S3 with a gallop. Jim had a myocardial infarction (MI) 15 years ago, and his currently on medication for hypertension.
Demographics: 69-year-old male
PMH: MI 15 years ago, HTN
SUBJECTIVE
- CC: The patient presents with dyspnea on exertion and has gained 25 lb. in the last seven months.
- HPI: 69-year-old male complaining of dyspnea on exertion, gain 25-pound weight in the last seven months. Report fatigue due to lack of sleep. A constant cough with a pink frothy color.
- Subjective: Questions to ask the patient
When did the dyspnea on exertion start?
Did you notice any swelling?
Has anything changed in your diet?
When you sleep, do you elevate your head on multiple pillows?
Does anything make dyspnea on exertion better? Worse?
When did the cough start? Have you taken any medication for the cough? Does the phlegm have an odor?
PMH: MI (15 years ago), HTN
MEDs: hypertensive medication.
Are taking any taking vitamins or supplements?
What is the name of your medication? What is the dosage? How often do you take it? How long have you been taking it for?
Are you allergic to any medication?. Denies food and environmental allergies. FH: Does anyone in your family have a history of: stroke, heart failure, cardiac arrest? Social Hx: Do you drink alcohol? If so, how often and how much? Do you smoke tobacco? Do you do any recreational drugs? Health Related Behaviors: Do you exercise? If so, how often? What is your diet like? Do you use a humidifier in your house?
OBJECTIVE
Check patient’s Vital sign – room air
General: Awake, alert, and oriented to time, person, place, and situation. The patient is ill and fatigued.
Skin: positive for bilateral lower extremities, cool to touch. Bilateral edema +3
Cardiac: positive for S3 with gallop. BLE 3+ edema.
Respiratory: room air, positive for dyspnea on exertion. Positive for a productive hacking cough with pink frothy “spit.”
Abdominal: positive for distended abdomen. Hepatomegaly noted.
Neurological: orientation normal, Motor function is normal. Memory is normal, and the thought process is intact.
Psychiatric: Appropriate mood and affect noted. Distress noted.
POC Testing: troponin, BNP, CBC, CMP, BUN/Creatinine, Urinalysis, rapid strep, ECG.
ASSESSMENT
- Working Diagnosis: Right heart failure, unspecified (ICD 10-CM I50.810)
- S3 with gallop, pink frothy sputum, weight gain, dyspnea on exertion, fatigue, peripheral edema, cough, hepatomegaly
- Differential Diagnosis:
- Chronic obstructive pulmonary disease, unspecified (ICD 10-CM J44.9)
- SOB, cough, lack of energy, leg swelling
- Pulmonary Embolism (ICD 10-CM I26.99
SOB, leg swelling, pink frothy sputum
PLAN
Diagnostic studies: BNP, CBC, CMP, BUN/Creatinine, Urinalysis, Sputum culture, ECG.
- Treatment
- Furosemide 20 mg once a day for 30 days. Dispend 30 tablets. No refill.
- Spironolactone 12.5 mg once daily for 30 days. Dispend 30 tablets. No refills.
- Enalapril 2.5 mg twice a day for 30 days. Dispend 75 tablets. 1 refills
- Losartan 25 mg once daily for 30 days. Dispend 30 tablets. 1 refills
- Entresto 49/51 mg sacubitril-valsartan twice daily. Dispend 60 tablets. 1 refills (Robinson,2023, p 280).
- Referrals: Cardiologists, Pulmonologist
- Education: Medication administration. The importance of medication compliance, notify the physician of weight gain of 3 pounds or more in 24 hrs. or 5 pounds weekly. Report all signs and symptoms.
- Health maintenance: Educate the patient on lifestyle modifications, regular exercise, strict fluid intake, and Immunization such as influenza pneumococcal. The importance of compliance with medication smoking cessation. Monitor sodium restriction to 2 g daily (Dunphy et al., 2023, p. 571).
- RTC: return in two weeks to monitor medication, adjust medication or change regimen if needed, monitor electrolytes, and assess patient health progress.
