riefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. May use approved medical abbreviations. Avoid redundancy and irrelevant information.

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To the writer this is the original post . The writer needs to answer the question asked by the professor see below .

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Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. May use approved medical abbreviations. Avoid redundancy and irrelevant information.

62 y/o Caucasian male presenting for persistent cough. Pt. report onset was 6mos ago. Location in chest region. Condition is intermittent and worse in the morning. Characterized as productive with white-yellowish phlegm. Aggravated with activity and relieved by rest. Pt. reports taking Robitussin DM without relief. Pt. now states that he is unable to walk >20ft without stopping to catch his breath (Last yr. at this time he could walk a mile without difficulty).

H/O:

PMH – Primary HTN Meds – Metoprolol succinate ER 50mg daily for HTN and Multivitamin daily Allergies – PCN (hives) Social – Prior smoker (20pk/yr. – quit when father died cold turkey) FMH – Father died at 59 due to MI & CHF (prior HX of diabetes, HTN and he was a smoker). Mother has osteoporosis. Siblings no health issues currently.

ROS:

(+) SOB

PE:

Alert, oriented in NAD, and able to speak in complete sentences.

Exam noted for the following:

WT: 258pds (obese) B/P: 156/94 O2 Sats: 94% RA (B) faint expiratory wheezing at the base of the lungs

Otherwise, unremarkable.

Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement (2-3 sentences) of pathophysiology for each.

Asthma

Pathophysiology: Is defined as a chronic inflammatory disease of the airway (Kennedy-Malone & Duffy, 2019). The pathophysiology of the disease is triggered by inflammation which can occur because of genetics, obesity, environmental factors, allergies, infections, tobacco use/exposure or pollution causing airway blockage, inflammation, irritability, or an attack (Fergeson et al., 2016).

Chronic Obstructive Pulmonary Disease (COPD)

Pathophysiology: Is defined as an inflammatory disease response causing airflow limitations because of inhaled toxins (Kennedy-Malone & Duffy, 2019). The pathophysiology of the disease can be due to genetic alpha-1 antitrypsin deficiency or inhaled toxins primarily cigarette smoke which causes small airway disorders, emphysema, systemic effects such decrease in airflow and destruction of lung tissue (Gentry & Gentry, 2017).

Heart Failure

Pathophysiology: Defined as the inability of the heart being incapable of pumping enough blood therefore, impairing ventricular filling or ejection of blood to supply systemic circulation (Kennedy-Malone & Duffy, 2019). The pathophysiology of the disease can occur because of trauma, a heart attack or blood clot resulting in Frank-Starling mechanism, myocardial hypertrophy, hypercontractility, cardiovascular changes, structural defects, rhythm abnormalities, increase metabolic demands, decrease output, declined stroke volume or diastolic/systolic dysfunctions (Wilkinson et al., 2019).

Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.

Asthma

ROS: (+) SOB, cough, unable to walk >20ft without stopping, and prior smoker 20pk/yr.

Positive findings: Faint (B) expiratory wheezing at lung base, Sats-94% RA, WT: 258pds (obese)

Negative findings: Resp-20bpm, lungs clear to auscultation (B), and respirations unlabored

COPD

ROS: (+) SOB, unable to walk >20ft without stopping, productive cough that produce white to yellowish phlegm, prior smoker 20pk/yr.

Positive findings: faint (B) expiratory wheezing at lung base, Sats-94% RA, WT: 258pds (obese)

Negative findings: Resp-20bpm, lungs clear to auscultation (B), respirations unlabored, (-) leg edema

Heart Failure

ROS: PMH: HTN, FMH: Dad deceased MI & CHF, (+) SOB, unable to walk >20ft without stopping, cough with white to yellow phlegm

Positive findings: B/P: 156/94, WT: 258pds (obese), Sats-94% RA, faint (B) expiratory wheezing at lung base

Negative findings: S1 and S2 with no murmurs, Temp: 98.1, HR:66, alert and oriented, able to speak in complete sentences, (-) leg edema, abdomen soft, tender no organomegaly, and lungs clear to auscultation (B).

Rank the differential in order of most likely to least likely.

1. COPD

2. Asthma

3. Heart Failure

Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based practice (EBP) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBP evidence.

Asthma – I would order a methacholine test which is the gold standard to diagnose asthma (Fergeson et al., 2016). A peak flow meter can be done to measure the peak expiratory flow rate, or a pulmonary function test could be used in addition to the above test to assess how well the patient’s lungs are working however, the methacholine test is the gold standard (Fergeson et al., 2016). Labs are not generally required except in severe oxygen saturation restriction in which that patient would need to be admitted and an arterial blood gas level could be assessed (Fergeson et al., 2016). A referral to an Allergist or Pulmonologist may be required depending on the patient’s test results/response (Fergeson et al., 2016).

COPD – Spirometry is required to diagnose COPD as the presence of a post bronchodilator FEV1/FVC <0.70 confirms airflow limitations (Gentry & Gentry, 2017). A peak expiratory flow measurement can be assessed however, this test alone is not a diagnostic tool (Gentry & Gentry, 2017). A referral to a Pulmonologist is a necessary supportive action as well (Gentry & Gentry, 2017). Heart Failure – Patient with suspected heart failure should have a thorough history taken, physical examination, and a series of test as there is no one test to make a final diagnosis such as an electrocardiogram (EKG), chest x-ray, computed tomography, echocardiogram, Holter monitor, blood test, B-type natriuretic peptide, and/or exercise stress test (Wilkinson et al., 2019). Depending on the patient’s symptoms I would start with an EKG, chest x-ray, blood test, B-type natriuretic peptide and advance from there depending on the patient’s symptoms and test results. A specialty referral to Cardiology is also a necessary supportive action (Wilkinson et al., 2019). References Fergeson, J. E., Patel, S. S., & Lockey, R. F. (2016). Acute asthma, prognosis, and treatment. The Journal of Allergy and Clinical Immunology. https://www.jacionline.org/article/S0091-6749(16)30800-4/fulltext (Links to an external site.) Gentry, S. & Gentry, B. (2017). Chronic obstructive pulmonary disease: Diagnosis and management. Journal of American Family Physician, 95(70, 433-441. https://www.aafp.org/afp/2017/0401/p433.html (Links to an external site.) Kennedy-Malone, L., Plank, L. M., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis Company. Wilkinson, M. J., Zadourian, A., & Taub, P. R. (2019). Heart failure and diabetes mellitus: Defining the problem and exploring the interrelationship. The American Journal of Cardiology, 124, 3-11. https://www.ajconline.org/article/S0002-9149(19)31173-7/fulltext Question asked by the professor You mention a valid concern in the HPI, regarding the cough with sputum, along with color, as part of the patient's overall assessment status. This fact may influence your overall approach to the patient's care. Carla or Peers - as far as patients who are believed to have COPD, does the presence of colored sputum suggest any other possible etiology? Can colored sputum be caused by any other diagnoses - and does colored sputum reflect any concern in those members with COPD?

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