CBC would be needed to diagnosis this (Dains, Baumann, & Scheibel, 2016). 3. Acute Bronchitis: Symptoms of acute bronchitis may include sore throat, fever, cough that produces mucus, chest congestion, shortness of breath, wheezing, chills, or body aches (Ball et al., 2015). Acute bronchitis should be differentiated from other common diagnoses, such as pneumonia and asthma, because these conditions may need specific therapies not indicated for bronchitis. Diagnostic tests to determine acute bronchitis include a chest x-ray, sputum test, and a pulmonary function test. 4. Chronic Obstructive Pulmonary Disease (COPD): Dyspnea may be intermittent, with or without environmental triggers, and is usually accompanied by dyspnea, cough, wheezing, sputum, and a history of smoking or industrial exposure. The most common symptoms clinical presentations of COPD are dyspnea, cough, fatigue, intolerance of physical activity and abnormal SA02 (Ball et al., 2015). Mr. H is a smoker and is experiencing dyspnea and a cough. He could be experiencing COPD exacerbation due to another cause or vice versa. 5. Pulmonary Embolism (PE): According to Dains, Baumann, & Scheibel (2016) “physical findings in a patient with a PE would be restlessness, fever, tachycardia, tachypnea, diminished breath sounds, crackles, wheezing, and pleural friction rub” (p. 171). A major risk factor for developing a PE is being a smoker and being overweight which are both things that Mr. H is during the visit. Some patients with pulmonary embolism may
have no obvious symptoms initially and some experience acute dyspnea that gradually gets worse. It is important to rule a PE out if other causes of his dyspnea are unknown. References 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. 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. Inamdar, A. A., & Inamdar, A. C. (2016). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical medicine, 5(7), 62. doi:10.3390/jcm5070062 Laureate Education. (Producer). (2012). Advanced health assessment and diagnostic reasoning. Baltimore, MD: Author. Tseng, Y. L., Ko, P. Y., & Jaw, F. S. (2012). Detection of the third and fourth heart sounds using Hilbert-Huang transform. Biomedical engineering online, 11, 8. doi:10.1186/1475-925X- 11-8 Responses: Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning. Response # 1 to Melissa Smith Great post Melissa, I think you did a great job on this weeks Soap note. As obvious as the diagnosis seems, I do believe the diagnosis of a pulmonary embolism is the most likely condition due to his symptoms. According to Dains, Baumann, & Scheibel (2016), a patient reporting severe dyspnea, cough, fever, hemoptysis, chest pain, and/or recent immobilization should be evaluated for a possible PE. Because I must choose one, I would reject the diagnosis of
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