Evaluating the Signs and Symptoms to Give a Diagnosis Discussion

A 72-year-old male presents to the clinic with 4 weeks of productive cough. He has a 10-year history of diagnosed COPD. He has a 45-year history of two packs a day cigarette smoking. He states he quit smoking due to financial needs about 6 years ago. He complains of pain in his chest from coughing, saying it is sore. He has noticed some dark-colored blood on his tissue.

Vital Signs: BP 137/90; HR 82; RR 22; BMI 23.

Chief Complaint: Persistent cough won’t go away with my normal cough medicine. Noticed blood on tissue from coughing.

Discuss the following:

1) What additional subjective information will you be asking of the patient?
2) What additional objective findings would you be examining the patient for?
3) What are the differential diagnoses that you are considering?
4) What radiological examinations or additional diagnostic studies would you order?
5) What treatment and specific information about the prescription will you give this patient?
6) What are the potential complications from the treatment ordered?
7) What additional laboratory tests might you consider ordering?
8) Will you be looking for a consult?

Submission Instructions:

  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

Expert Solution Preview

Introduction:

In this scenario, a 72-year-old male with a history of COPD presents to the clinic with a persistent cough, chest pain, and dark-colored blood on his tissue. As a medical professional, it is imperative to gather additional subjective and objective information from the patient, consider differential diagnoses, and order appropriate diagnostic studies to provide the best treatment plan for the patient.

1) What additional subjective information will you be asking of the patient?

In addition to the patient’s chief complaint, it is essential to ask about the duration, frequency, and nature of the cough. The medical professional should inquire about any recent respiratory infections, exposure to irritants, or allergens. It is also crucial to ask about the presence of shortness of breath, wheezing, chest tightness, or fever. The clinician should ask the patient about any recent changes in medications, including any use of over-the-counter cough medications.

2) What additional objective findings would you be examining the patient for?

The healthcare provider must conduct a physical examination to assess the patient’s vital signs, oxygen saturation, lung sounds, and chest pain. The clinician should examine the patient’s throat and nasal passages for signs of inflammation or congestion. Examination of the chest should include percussion, palpation, visual inspection, and auscultation. The clinician should also examine for signs of cor pulmonale and peripheral edema.

3) What are the differential diagnoses that you are considering?

In this case, the differential diagnosis includes COPD exacerbation, pneumonia, lung cancer, tuberculosis, and bronchiectasis. The possibility of pulmonary embolism should also be considered if there is evidence of blood clots in the sputum.

4) What radiological examinations or additional diagnostic studies would you order?

The clinician should order a chest X-ray to evaluate for any structural abnormalities, including masses or effusions. Pulmonary function tests should also be considered to assess the severity of COPD. A blood test and sputum culture can help identify the organism causing the infection. The clinician should also order a CT scan if there is a suspicion of malignancy or an abscess.

5) What treatment and specific information about the prescription will you give this patient?

Treatment for the patient might include supplemental oxygen, bronchodilators, corticosteroids, and antibiotics if a bacterial infection is suspected. The clinician should advise the patient to quit smoking and follow their prescribed medication regimen. Specific information should be given about the side effects of the medication and the proper administration of inhalers.

6) What are the potential complications of the treatment ordered?

Complications of prescribed treatment could include allergic reactions to medication, antibiotic-associated diarrhea, and bronchospasm. Possible side effects of bronchodilators and steroids include tremors, insomnia, heart palpitations, and mood changes.

7) What additional laboratory tests might you consider ordering?

Additional laboratory tests might include arterial blood gas analysis, serum electrolytes, and complete blood count (CBC) with differential. These tests may help in the diagnosis and management of COPD exacerbations and pneumonia.

8) Will you be looking for a consult?

In this case, considering the patient’s symptoms, it would be appropriate to seek a consultation from a pulmonologist. The pulmonologist can further evaluate the patient and provide recommendations for management.

In conclusion, obtaining a complete history, physical examination, and the use of appropriate diagnostic testing is necessary to manage patients with respiratory illnesses. As medical professionals, it is crucial to convey to the patient the importance of quitting smoking for improving health outcomes.

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