Presentation: 52 year old male presents with complaint of wet cough and intermittent fevers for one week. Symptoms have progressively worsened with onset of back pain over the last two days.
Previous Medical History: No health insurance and has not seen provider for five years. History of Hypertension, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus-2 controlled with diet.
Allergies: Penicillin and Erthyromycin
History of Present Illness: Onset/duration: one week. Pattern: cough worse at night. Associated Symptoms: fever and back pain worsens with coughing. Relieving factors: sitting up and drinking fluids. Aggravating factors: smoking and lying down. Effect on Activities of Daily Living: fatigue and cannot sleep. Home Treatment: Nyquil and Tylenol. Exposures: grandchild had a runny nose and cough.
Vital Signs: Temperature 100.4 orally, Pulse 88, Respirations 28, Blood Pressure 148/92 in Right arm, Weight 220 pounds, Random Blood Sugar (RBS) 368.
Current medications: not known
1. Questions for History:
How long have you had your symptoms? How severe are they? What parts of the body are affected and do the symptoms change over time? Do they come and go or are they all the time? Do they make it hard to work, function at home, or behavior in a regular manner? If so, in what respect? Do you know what makes the symptoms happen or what makes them better or worse? Have you ever had these same symptoms before and if so, what did you do to relieve them? Have you noticed any other symptoms?
What made you seek medical help today? Did your symptoms change in some way? Did something happen to make you think they are serious?
Besides the problem that brought you in today, do you have any other medical conditions? Have you been to the doctor for treatment before or in the hospital? If so, what were you told at that time? Have you ever had an X-ray or an operation? If so, when was this? Were there any serious problems at that time?
Are you taking any prescribed or over-the-counter medication or herbal remedies? If so, what is the dose and why are you taking it? Have you ever had an allergic reaction to any medications?
Have you ever smoked and if so, how much? Do you drink alcohol and if so, how much. Do you now or have ever taken recreational drugs?
(women) Have you had any pregnancies? If so, were there any problems with any of them? Have you ever had breast exams, pap smears, or other types of tests? (men) Have you ever had a prostate exam or other types of tests?
Are you sexually active and if so, do you have more than one partner? Are any partners of the same sex? Do you use protection of any type? Have you ever had an STD?
(Arrizabalaga/online journal, 2015)
2. Physical Exams Needed:
Hypertension: Blood pressure should be taken in both arms to evaluate vascular abnormalities and routine lab work with a possible 12-lead electrocardiogram to determine possible causes and risk factors, the presence of end-organ disease, and baseline values for therapeutic biochemistry (Brown, 2003, p. 180). The recommended goal is 139/89 mm Hg or less. While present weight is only 220 pounds, if it difficult to determine if the patient is overweight due to lack of information on current height. Current physical examination needs to take a height, weight, and waist circumference measurement with the patient standing and the body mass index calculated. A retinal examination is needed for determination, also. Heart rate should be taken with the patient at rest since an increased heart rate points to heart disease. The legs should be checked for signs of edema, and pulses should be taken in several places including the wrists, tops of the feet, and neck. The physician should listen to the abdomen for sounds of abdominal bruits. The neck should also be palpated for signs of an enlarged thyroid gland, inspected for distended neck veins, and listened for carotid artery bruits. The patient should also be questioned for a history of neurologic indications of transient ischaemic attacks or stroke, syncopal episodes, and palpitations ( Mancia, Fagard, and Narkiewicz K, et al,. 2013 p. 1293). Diabetes Mellitus 2: Exam extremities for signs of insufficient blood supply leading to necrosis such as ulcers. Question for signs of neuropathy, polyuria, or retinopathy as these are indications blood sugar has not been undercontrol. Look for hemorrhages in the eye, absence of light touch or temperature sensation, claw toes, muscle atrophy, or decreased deep tendon reflexes. Evaluate dorsalis pedis and posterior tibialis pulses for blood flow.
Chronic Obstructive Pulmonary Disease: Evaluate quality of breath sounds, decreased breath sounds, wheezing, and whether it takes longer to breathe out than in. Visually evaluate for barrel chest appearance, pursed lip breathing, and cyanosis of the fingers or lips (Gruber, 2008, p. 565). As with hypertension, measurements should be taken of body temperature, weight, and the body mass index calculated. In conjunction with the symptoms of an upper respiratory infection or bronchitis, the nose, eyes, throat, and ears are checked for infection. Heart and lungs are evaluated with a stethoscope. Neck veins are checked for extension, indicating cor pulmonale or other heart problems. Abdominal auscultation is performed and edema of the fingertips and legs.
Upper Respiratory Infection/Bronchitis: Acute bronchitis is difficult to distinguish from an upper respiratory infection during the first few days; however, a bronchial cough will continue for ten to twenty days. Physical examination may reveal redness inside the nasal cavity, swelling, throat redness, tonsil enlargement (if present), tonsil exudates, enlarged lymph nodes of the head and neck, red eyes, and facial tenderness from sinusitis.
3. Diagnostic Tests:
Hypertension: Urinalysis, fasting blood glucose, hematocreit, potassium, serum sodium, creatinine, calcium, and a lipid profile with a 9- to 12-hour fast; decreased Glomerular Filtration Rate (GFR) level with albuminuria indicates an increased cardiovascular risk (Brown, 2003, p. 180). In order to assess possible secondary causes, and complete blood count, chest x-ray, urine microalbumin, and uric acid may be indicated (Chobanian et al., 2003, p. 1210). An echocardiography is useful in determining cardiovascular and renal risk and should be considered (Mancia et al,. 2013 p. 1296). An elevated amount of albumin the in the urine may indicate hypertensions-induced renal damage (p. 1298).
Diabetes: Several tests are used to determine HbA1c levels; the diagnosis is based on a level of 6.5% or higher. One test is a fasting plasma glucose (FPG) level with no caloric intake for at least 8 hours. A 2-hour plasma glucose level can also be done during a 75-g oral glucose tolerance test. An alternative is a random plasma glucose if there are symptoms of hyperglucemia (“Diagnosis and Classification of Diabetes Mellitus”, 2010, online). A glycated hemoglobin (Ac1) will show the average level of blood sugars over the last two or three months; this level should be checked every six months or so. In addition, it is recommended that diabetic patient receive an annual screening for microalbuminuria; the patient has not seen a physician in five years, so this test should be conducted. A common finding in Diabetes Mellitus-2, microalbuminaria is a risk factor for coronary heart disease.
Chronic Obstructive Pulmonary Disease: Spirometry can be used to determine the presence and extent of the involvement (Vestbo, 2013, p. 11); lung volume may also be measured through body box, nitrogen washout, or helium dilution. A diffusing capacity test may be performed to determine the amount of lung tissue containing air that is coming into contact with blood, the amount of red blood cells, and the thickness of the walls of the air sacs. Testing the arterial blood gas and oximetry evaluates the gas exchange in the lungs. A chest x-ray or cat scan may also be ordered.
Upper Respiratory Infection/Bronchitis: Throat culture with swabs to confirm bacterial pathogens (Shulman et al., 2012, online publication). While tests are not generally needed for a standard upper respiratory infection, the patient had been exposed to a grandchild with possible bacterial contamination. If sputum is produced, a sample should be tested to decide if antibiotics are indicated.
4. Top four differentials for presenting symptoms and most likely diagnoses with rationale:
Hypertension: History of diagnosis. Stage 2 hypertension is defined as a systolic blood pressure reading of greater than160 mm Hg or diastolic blood pressure reading of greater than 100 mm Hg; patient presents with a blood pressure reading of 148/92 which indicates hypertension is under control (Brown, 2003, p.181). According to the guidelines set down by in 2013 by the ESH/ESC for aterial hyptertension, a blood pressure measured in the office has a relationship to the number of cardiovascular event as well as endstage renal disease (Mancia et al,. 2013 p. 1285). In the same publication, the definition and classification of office blood pressure levels indicate the patient falls into the category of Grade 1 Hypertension (p. 1286).
Diabetes mellitus-2: History of diagnosis. Discuss with patient the following presence of symptoms, particularly in light of a five year history of not seeing a physician (possible long-term uncontrolled blood sugar): excessive thirst or urination, extreme fatigue, blurred vision, dry and itching skin, yeast infections between fingers and toes or in around sexual organs, sores or cuts that heal slowly, and pain or tingling or possibly numbness in the feet or hands.
Chronic Obstructive Pulmonary Disease (COPD): History of diagnosis. Symptoms of cough, a cold, history, and exposure to risk factors (smoking, age) indicate presence of the disease (Vestbo, 2013, p.14). Symptoms of COPD are exacerbated in 50-75% of cases by infections such as the possible upper respiratory infection exhibited by the patient (Dhar, 2011, p. 1056). In addition, a chest x-ray and arterial blood gas may be indicated.
Upper Respiratory Infection/Bronchitis: A streptococcal infection is not suspected due to level of fever. Determination of bacterial infection indicated. Testing allows prevention of the use of unnecessary antibacterials ( Mancia et al,. 2013 p. 1316). Symptoms of cough and low-grade intermittent fever are consistent with upper respiratory infection.
5. Comprehensive treatment plan while waiting for test results:
Hypertension: Limit salt intake to about 5 to 6 grams per day (O'Riordan, 2013, online publication). He can be prescribed a combination of an ACE inhibitor and a thiazide diuretic, a calcium channel blocker, or an angiotensin receptor blocker (Brown, 2003, p.180). The patient may be encouraged to obtain a blood pressure cuff for the purposes of daily readings.
Diabetes Mellitus-2: Continue diabetic diet and self-monitoring with recording of glucose levels for the return office visit. Promote good skin and oral care. Stress the importance of regular eye and dental exams and continued visits for evaluation of diabetes as insulin may be required as the diseases progresses. Educate the patient on signs of high blood sugar and instruct him to contact the office for symptoms of hyperglycemia. If the patient states he will continue to drink alcohol, encourage him to do so with meals and to have no more than two drinks per day to keep blood sugar levels in control.
Chronic Obstructive Pulmonary Disease: Promote enrollment in a program to stop smoking. Probable prescription for Levoquin due to penicillin and erythromycin allergies. Bronchodiators are an option for relief of discomfort associated with coughing (Decramer, Janssens & Miravitlles, 2012, p. 1349). Corticosteroids may also be used in conjunction with bronchodilators as an option.
Upper Respiratory Infection/Bronchitis: Rest, fluids, acetaminophen for fever and aching, over-the-counter antihistamines for congestion and antitussives for cough. Bronchodilators or inhaled steroids may be prescribed. Humidifiers or cool mist appliances may decrease discomfort.
6. Health promotion topics:
Hypertension: Focusing on control of blood pressure through medication, diet, and exercise. Measure blood pressure daily, on exertion, or if symptoms of high blood pressure present themselves. It has been documented that home blood pressure readings are more predictive of cardiovascular morbidity and mortality than readings taken in other locations (Mancia et al., 2013, p. 1291). Recommendations seek to avoid surgical intervention of secondary complications, although surgery is not recommended for high blood pressure. Educate the patient on the signs of stroke. While a MRI (Magnetic Resonance Imaging) is desirable to detect silent cerebrovascular lesions which are more prevalent than renal or cardiac subclinical occurrences, the cost to a patient without health insurance may be prohibitive (p. 1299).
Diabetes Mellitus-2: Focusing on eliminating symptoms and development of complications. Achieved through control of hypertension, smoking cessation, and healthy diet to control glycemia. Evaluate knowledge of diet techniques. Consider use of metaformin as studies have shown it increases life expectancy (Ripsin, Urbam, and Kang, 2009, p. 31). Promote importance of self-monitoring of blood glucose (“Diagnosis and Classification of Diabetes Mellitus”, 2010, online). Review the importance of daily foot examination and proper care.
Chronic Obstructive Pulmonary Disease: Education on risk factors and progress of the patient’s disease. Promote exercise and stopping smoking. It may become necessary to put the patient on oxygen administration as needed through a nasal cannula if symptoms become severe. A physical therapist can recommend breathing techniques that promote optimum oxygen exchange. In addition to stopping smoking, the patient should avoid secondhand smoke and fireplace smoke or other pollutants. It may be recommended to get annual flu shots and the pneumonia vaccine to decrease the possibility of additional infection to the body. Breathing may be improved by avoiding cold air. Drugs prescribed by the physician should not be discontinued without his permission, even if symptoms improve. If activities of daily living have become difficult, such as bathing or dressing, the assistance of an occupational therapist may be enlisted to address modifications.
Upper Respiratory Infection/Bronchitis: Practice good handwashing and avoid contact with contaminated people. Rest with the head elevated, fluids, and a healthy diet assist in prevention of re-infection. Again, bronchodilators or inhaled steroids may be prescribed. The use of humidifiers or cool mist appliances may decrease discomfort due to coughing. As with chronic COPD, stopping smoking is highly recommended for treatment of bronchitis.
7. Follow-up will take place within one month.
The goal blood pressure needs to be review within one month to determine if the dosage of the hypertensive medications are effective. Patient should call back if symptoms of upper respiratory infection do not subside within ten days. Bronchitis may last up to ten days; if temperature rises over 101F or if symptoms become worse, come back before the next appointment. Status of blood sugars for evaluation of diabetic management may be performed at the blood pressure visit.
When a patient shows signs of multiple systems involvement, it is recommended he return for physician evaluation every three or four months with additional visits in the event of symptoms that become concerning.
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