week 3 discussion

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South University, Savannah *

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6020

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Medicine

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Feb 20, 2024

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Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 28: 58-year-old male with shortness of breath. You are required to answer all the DISCUSSION QUESTIONS listed below in each domain. DOMAIN: HISTORY 1a) Identify two (2) additional questions that were not asked in the case study and should have been? 1b) Explain your rationale for asking these two additional questions. 1c) Describe what the two (2) additional questions might reveal about the patient's health. I feel it is important to ask the patient if he has any seasonal or food allergies that have worsened or maybe that he didn’t know of before. I went back through the questions and history and I didn’t notice that any allergies were listed. It has been a while since his last visit and sometimes as the weather changes, allergy or sinus problems could be exacerbated or exacerbate other underlying issues. It would also be very important to know of any allergies before prescribing any medications to prevent any potential reactions. Though the patient described it as “white phlegm” I would like to ask him if he ever coughs up any phlegm or sputum of different color or texture. If so could he tell me about when it happens? Does this only occur at certain times of the year, of the day or after he does certain activities? Describing exacerbating factors could really assist in understanding or finding potential diagnoses. DOMAIN: PHYSICAL EXAM For each system examined in this case; 2a) Explain the reason the provider examined each system. It has been a while since this patient’s last visit and he has very limited medical history, so it is pertinent to get a thorough review of each system. Because Mr. Barley is here with a respiratory complaint it will be important to pay special attention to the respiratory system and even the cardiovascular system because it could have respiratory effects. An extremely thorough HEENT assessment would be imperative as well because of the patient’s respiratory complaint. Though the physical exam can be more focused on the area of complaint, it is still important to get a full physical exam as to be able to rule out any possible errors in diagnosis and also the possibility to connect diagnoses with multiple symptoms. 2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient's age, describe what exam findings could be abnormal. Important abnormal findings would be any adventitious sounds that are superimposed on the usual breath sounds such as crackles, wheezes, and rhonchi (Bickley, 2020). Mr. Barley is found to have

inspiratory crackles, expiratory wheezes, an increased AP diameter, and an increased respiratory rate of 22 breaths per minute which are all abnormal findings. Mr. Barley had a murmur which is an abnormal cardiovascular finding. Any cervical lymphadenopathy, itching, swelling or redness of the eyes, or drainage from the eyes ears or nose would be abnormal findings from the HEENT exam. Mr. Barley had pitting edema noted in his lower extremities, that is an abnormal finding. 2c) Describe the normal findings for each system. This patient alert and oriented x4 Pupils equal, round, reactive to light. Ears with no swelling or drainage, no difficulty hearing Nose: no swelling of the inferior turbinate, or drainage present. Throat: Normal appearing; no signs of postnasal drainage, erythema or swelling. Neck: No jugular venous distension with the head of the exam table elevated to 45 degrees; normal carotid pulses; normal thyroid; no lymphadenopathy. Chest: No respiratory distress; normal, symmetrical expansion of the lungs; all areas resonant to percussion; breath sounds heard in all lobes with no adventitious sounds noted. Cardiovascular: Normal S1 and S2 without murmurs. No S3 or S4 heard. Skin: Skin warm and dry to touch, No skin lesions or lacerations, no areas of eczema or rash were noted. 2d) Identify the various diagnostic instruments you would need to use to examine this patient. In order to conduct a proper assessment of this patient a stethoscope, an ophthalmoscope, a thermometer, a pen light, a pulse oximeter, and a sphygmomanometer would be necessary. DOMAIN: ASSESSMENT (Medical Diagnosis) Discuss the pathophysiology of the: 3a) Diagnosis and, COPD usually characterized by chronic cough with sputum production. The symptoms are worse on exertion. On physical examination, lung sounds are diminished. The patient develops a “barrel chest” in which the AP chest diameter is greater than the lateral diameter as the COPD advances (Gooslby, 2018). 3b) Each Differential Diagnosis Asthma is a chronic condition that involves inflammation of the airways, with varying degrees of airway obstruction and hyperresponsiveness, is usually associated with wheezing and can be worsened by exposure to allergens (Goolsby, 2018).

DOMAIN: LABORATORY & DIAGNOSTIC TESTS Discuss the following: 4a) What labs should be ordered in the case? 4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis. A spirometry test to show lung capacity. COPD can be diagnosed with a FEV1/FVC of 0.7 and anything greater would be graded into stages of severity. A chest x ray just for confirmation of the status of the patients lungs. 4b) Discuss what lab results would be abnormal. Abnormal would be FEV of less than 80% and if the chest x ray showed infiltrates or white areas of consolidation on the lungs. 4c) Discuss what the abnormal lab values indicate. Both of these abnormal results could mean an obstruction of some point of your respiratory tract. 4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group. n/a Reference Bickley, L. (2020). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer Health. ISBN: 9781496398178 Goolsby, M. J. & Grubbs, L. (2018). Advanced assessment: Interpreting findings and formulating differential diagnoses (4th ed.). F. A. Davis Company. ISBN: 9780803668942

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week 3 discussion

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