Description
Analyze the possible conditions from your colleagues’ differential diagnoses. of the provided soap note Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
Case #3
Patient Information: HL 64years, White Male.
Subjective Data
Chief Complaint: The patient presents to the clinic with the complaints of cough with sputum and shortness of breath since past five days.
History of Present Illness: 64year-old HL White male is here with the complaints of cough and shortness of breath (SOB) since past five days. He says sputum is green and sometimes with blood. SOB worsens with walking and talking.
Current Medications:
OTC: Tylenol 650mg 3x daily
Allergies: No allergies to medication, food, and environment.
Past Medical History: Denies past surgery, hospitalization or any accidents. No immunization data given. No history of any chronic diseases like diabetes mellitus, hypertension, heart diseases, or stroke.
Social History: No data given for occupation, major hobbies, family status, alcohol and smoking history, or drug abuse. Living environment is safe, uses seatbelts, no cellphone use while driving, and home has working smoke detectors.
Family History: No history of illnesses with possible genetic predisposition, no contagious or chronic illnesses. No history provided about the family member.
Review of System:
GENERAL: Fever, chills, sweat, weakness or fatigue.
HEAD: No headache, no history of head injury
EENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching, warm and moist
CARDIOVASCULAR: Chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Shortness of breath, cough
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination, urgency or frequency
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Objective Data:
Vital Signs: BP 128/70; T 100.9; P 82; R 20 (labored); O2 89%; Weight 210lbs
Physical exam:
GENERAL: Fever, chills, sweat, weakness or fatigue.
HEAD: No headache, no history of head injury
EENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching, warm and moist
CARDIOVASCULAR: Chest pain, chest pressure or chest discomfort. No palpitations or edema. Heart rate and rhythm with S1 and S2 sound, no S3 and S4 sound, no murmur. Pedal pulse palpable bilaterally.
RESPIRATORY: Thorax symmetrical, breath sound diminished, rales and expiratory wheezing heard at all lobes bilaterally. Dullness to percussion and well productive cough noted.
GASTROINTESTINAL: Abdomen soft non-tender upon palpation, bowel sound active in all quadrants.
Diagnostic results: According to HL’s symptoms and the results of the PE, chest x-ray, and CBC, it is recommended that patient undergoes sputum culture for suspicion of pneumonia. The results of all the exams showed HL showing the symptoms (e.g. productive sputum, chest pain, rale sounds, etc.) (Epocrates, 2018).
Assessment:
Differential Diagnosis:
Bacterial Pneumonia: Chills, fever, rapid onset of cough hours to days with chest pain and shortness of breath, cough with sputum production is common with bacterial pneumonia (Ball, Dains, Flynn, Solomon, & Stewart, (2015). Chest radiography, complete blood count, sputum and nasal bacteria culture will confirm if a patient has pneumonia. (Dains, Baumann & Scheibel, 2016). Thus, actual diagnosis is bacterial pneumonia.
Acute Chronic Obstructive Pulmonary Disease (COPD) Exacerbation: COPD is a condition primarily consisting of emphysema and chronic bronchitis. The symptoms include worsening dyspnea, cough, increase in sputum purulence, tachypnea, fever, increased wheezing, and respiratory rate (Dains, Baumann & Scheibel, 2016). COPD is ruled out since there is no show of increased heart rate, barrel chest or airflow obstruction.
Asthma: Spirometry with post bronchodilator response should be obtained as the primary test to confirm if a patient has asthma while pulse oximetry measurement is recommended to patients with acute asthma to exclude hypoxemia (Ekerljung et al, 2018). The patient shows signs of coughing, wheezing, shortness of breath, chest pain/tightness – symptoms of asthma.
Acute Bronchitis: Bronchitis is characterized by inflammation of the bronchial tubes (bronchi), the air passages that extend from the trachea into the small airways and alveoli (Michaelidis, 2015). To confirm a diagnosis, there is a need for a complete history and pertinent data such as toxic elements exposure, and smoking. Symptoms include cough, fever, sputum production, general malaise, and chest pain (Fayyaz, 2018).
Viral Pneumonia: Pneumonia symptoms involve headache, low-grade fever, cough and malaise (Cavallazzi & Ramirez, 2018). This disease may be classified as mild and self-limited illness to a life-threatening disease according to the age and comorbidities of the patient. Symptoms of viral pneumonia include fever, chills, cough with sputum, shortness of breath, rhonchi, rales, wheezing, dullness to percussion, decreased breath sound, fatigue (Cavallazzi & Ramirez, 2018). Basing on HL’s health data, viral pneumonia is a possible diagnosis.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Cavallazzi, R., & Ramirez, J. A. (January 01, 2018). Influenza and Viral Pneumonia. Clinics in Chest Medicine, 39, 4, 703-721.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Michaelidis, C. I., Kern, M. S., & Smith, K. J. (January 01, 2015). Cost-Effectiveness of Decision Support Strategies in Acute Bronchitis. Journal of General Internal Medicine, 30, 10, 1505-1510.
Ekerljung, L., Mincheva, R., Hagstad, S., Bjerg, A., Telg, G., Stratelis, G., & Lo¨tvall, J. (2018). Prevalence, clinical characteristics and morbidity of the Asthma-COPD overlap in a general population sample. (Journal of asthma.)
Sample Solution
