Reference no: EM133944988
Assignment
A 70-year-old male presented to the clinic with shortness of breath, which progressed over the last week. He reports constantly feeling short of breath when the season changes. He reports being evaluated by a lung doctor a few years ago but has never followed up. He has had his COVID vaccine series for 2021. He has a history of hypertension, hyperlipidemia, and cataract surgery. He reports quitting drinking alcohol about 10 years ago but continues to smoke (unfiltered) 1.5 packs per day for the last fifty-plus years. He lives alone, is a widow, and has his children living out of state. Retired from the construction industry. He does have a dog, and he notices he has been having difficulty walking the dog due to shortness of breath. He admits to a smoker's cough every morning, which can be productive at times. Denies fever, chills, or ill contacts. Has had some weight loss but attributes it to decrease appetite and not wanting to make meals for one person. Denies chest pain, swelling, nausea, vomiting, or depression. Medications: losartan-hydrochlorothiazide (Hyzaar) 50-12.5 mg daily PO; atorvastatin (Lipitor) 40 mg PO Daily; ASA 81 mg PO daily. On exam, cachectic with orbital fat loss, well-groomed male, looks older than stated age. Height 5'5" and 126 pounds. Appears tachypneic at 20 breaths per minute with pursed-lip breathing, no edema on exam or JVD. HR regular rate and rhythm around 78 beats per minute. Afebrile, 98.4 oral temperature. Blood pressure on RUE 109/49 mmHg. Oxygen saturation 91% on room air. Breath sounds reveal expiratory wheezing but diminished to the right upper base. The abdomen is soft, and bowel sounds are present in all 4 quadrants. Distal pulses present in all extremities, +2; capillary refill about three seconds; yellow discoloration to fingernails.
Chest x-ray from 2 years ago is on the right:
Spirometry from 2 years ago:
Forced vital capacity (FVC):
1) Actual 2.00L
2) Predicted 3.77L (53% predicted)
3) Post-bronchodilator 2.03L (53% predicted, changed +1%)
Forced expiratory volume in 1 second (FEV1):
1) Actual 0.80L
2) Predicted 2.66L (30% predicted)
3) Post-bronchodilator 0.78L (29% predicted, change -3%)
FEV1/FVC ratio (ACTUAL): 0.80L/2.00L (40%)
Task
A. With the above information, construct the patient's data into a SOAP Note format.
B. Based on the information provided at this time, what are your differential diagnoses (place under the Assessment section of the SOAP note)? Provide support or clinical reasoning based on pertinent positive and negative findings.
C. What additional information (i.e., history, ROS, PE, diagnostics) would you want to know to help establish your principal diagnosis?
D. Include a management plan for the likely principal diagnosis, and list other active diagnoses.
E. What are your interpretations of the chest x-ray and the pulmonary function test? Get the instant assignment help.
F. Pose two open-ended questions for your peers to respond to regarding questions you may have experienced researching the topic or required unit material.