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Case 2

Respiratory A 58 year old man comes to the office because of shortness of breath. He has experienced mild dyspnea on exertion for a few years, but more recently he has noted worsening shortness of breath with minimal exercise and the onset of dyspnea at rest. He has difficulty reclining and has been sleeping in his recliner for the past month. He has noted a cough with yellowish-brown sputum for the past few months in the AM. He denies chest pain, fever, chills or lower extremity edema. He was evaluated at an urgent care center a few months ago and was given an inhaler and referred to a primary care provider. He does not recall the name of the inhaler and has used it only intermittently. PMH: “prediabetic”- treated with diet and exercise (walking) Erectile dysfunction- takes Viagra prn Basal cell carcinoma-side of left nose- treated with Moh’s procedure- 5 years ago Blepharitis and early cataract formation Medications- none PSH: right hernia repair at age 50, repair of left rotator cuff at age 53, septoplasty- age 16 Social: Married, Works in sanitation, Has 3 children, Smokes 1 ppd x 40 years, ETOH- a few beers on weekend FH: father- age 86, CAD, Afib, arthritis, Mother- age 85 uterine cancer, meniere’s disease, basal cell carcinoma x 2. Brother- age 56 HTN, hyperlipidemia PE: BP 138/92 RA sitting, heart rate- 92 regular, respiratory rate- 26bpm, temp 97.8 F oral Ht: 5’9” Wt 190 lbs. BMI- 28 Pt appears slightly anxious, talking quickly, sitting in chair and leaning forward. His respirations are slightly labored with use of accessory muscles CV: distant heart sounds, AP- 92 regular, S1, S2 no M/R/G, no JVP distension, no edema or clubbing Resp: AP diameter slightly increased with inward movement of the lower rib cage with inspiration, Percussion- generalized hyperresonance , + wheezes and rhonchi bilaterally, no crackles, fremitus- decreased, bronchophony-negative
 
1. What are your differentials? State positive and negatives, what is the most likely diagnosis?
 
2. What is the next best diagnostic test? Go into detail about the testing
 
3. What is the best initial treatment?
 
4. What is your management plan for this patient regarding this condition include follow-up
 
5. What other Health promotion and disease prevention strategies would you initiate? Be specific
 
6. Use APA reference

RNSG 1209 Introduction to Nursing

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