Miami Dade College 55 Year Old Homeless Man with Nursing Assignment Help

Case Study Chosen:

Mason, a 55-year-old homeless man with respiratory symptoms.

Demographics:

Age: 55 Gender: Male

Mason, a 55-year-old homeless man with respiratory symptoms and related findings from the examination, here are appropriate questions to ask Mason during the initial assessment:

1. General Health:
   • Can you describe your overall health and any chronic medical conditions you are aware of?
   • Are you currently taking any medications or have any known allergies to medications?
   • Do you have a history of frequent colds or respiratory infections?
2. Respiratory Symptoms:
   • When did you first notice the morning cough and frequent colds? How long have you experienced these symptoms?
   • Can you describe the cough in more detail (productive/non-productive, color and consistency of sputum)?
   • Have you noticed any triggers or specific activities that worsen your difficulty in breathing?
3. Smoking History:
   • How long have you been smoking, and how many cigarettes do you smoke per day?
   • Have you ever attempted to quit smoking, and if so, what strategies or treatments have you tried?
4. Physical Activity and Mobility:
   • Can you elaborate on how your shortness of breath has progressed, especially with everyday activities? Are there specific activities that have become particularly challenging?
   • How long have you experienced difficulty walking long distances, and has this affected your ability to find food and access resources?
5. Breathing Patterns and Symptoms:
   • Have you noticed any changes in your breathing pattern, such as rapid breathing or increased effort to breathe?
   • Do you experience chest pain or discomfort while breathing, especially during exertion or at rest?
   • Have you ever been told that you make a sound when you breathe, like wheezing or whistling?
6. Cardiovascular Health:
   • Have you ever been diagnosed with high blood pressure or other heart-related conditions?
   • Do you experience any chest pain, palpitations, or irregular heartbeat?

SUBJECTIVE:

CC: Difficulty breathing and seeking medicine to help survive on the streets.

HPI:

• Subjective: Shortness of breath during physical activity, difficulty breathing with everyday activities, frequent morning cough, limited mobility due to breathlessness.

OBJECTIVE:

General:

• VS: 99°F, HR: 100 bpm, RR: 28/min, BP: 140/90 mmHg
• Weight, Height, BMI: Not available

Physical Exam Elements:

• Respiratory system: Distant breath sounds, end-expiratory wheezes, use of accessory muscles to breathe, slight barrel chest, neck vein distention.

POC Testing:

• None mentioned in the case study.

ASSESSMENT:

Working Diagnosis (ICD-10):

• COPD (Chronic Obstructive Pulmonary Disease) – J44.9

Differential Diagnosis:

1. Asthma – J45.909
2. Acute Bronchitis – J20.9

PLAN:

Diagnostic studies:

• Pulmonary function tests (spirometry, lung volumes, diffusing capacity) for definitive COPD diagnosis.

Treatment:

• COPD Management:
  • Inhaler therapy (e.g., salbutamol/albuterol, ipratropium)
  • Smoking cessation counseling
  • Pulmonary rehabilitation referral

Referrals:

• Pulmonary specialist for further evaluation and management.

Education:

• Educate on COPD, smoking cessation, importance of medication compliance, and seeking medical care.

Health maintenance:

• Encourage regular follow-ups, adherence to medication and pulmonary rehabilitation programs, and annual influenza vaccination.

RTC (Return to Clinic):

• Follow up in 2 weeks to assess response to treatment and adjust the management plan as needed.

Diagnosis Table: