APA format 3 peer review article references Due 10/12/18 at 5pm
Patient Information:
Mr. H, Age 58, Male, White
S.
CC: Chest Pain “Shortness of breath with severe pain on deep inhalation” (according to Dains, Baumann, & Scheibel, (2016) before a complete HPI is taken this patient must be a quickly assessed as this complaint can have rapid, life-threatening consequences).
HPI: Reports a constant chest pain for two days ago, taking a full breath makes it worst (inhalation), pain is sharp and severe with a current PIS of 8. Subject feel like his heart is racing. Nothing makes the chest pain better. The patient also has exhibited signs and symptoms of a cough, “spit up blood,” right leg swollen and red. He recalls being stationary for an eight-hour period while on a plane, in the economy section middle row, recently from vacationing in Europe, without bathroom overall usually has a sedentary lifestyle mostly due to working 9 am -5 pm as a customer service representative at a call center. After work he sits in front of the television and watches various programs for about four hours while eating dinner, drinking a can of beer or two and smoking a cigarette before bed. It started two days ago when the patient was running to clock in at work, to avoid being late.
Location: right chest pain
Onset: 2 days ago
Character: Sharp and constant
Associated signs and symptoms: a cough, elevated heart rate, and most recently expectoration of blood.
Timing: running to avoid being late for work
Exacerbating/ relieving factors: activity makes it worst. Nothing relieves the pain.
Severity: 8/10 pain scale
Current Medications: Hydrochlorothiazide 25 mg daily for six months, and Norvasc 5 mg twice daily from one month ago for hypertension, Lipitor 80 mg daily for high cholesterol; However, has not been compliant. The patient also stated that he was taking thiamin 100 mg, folic acid 250 mcg and vitamin D 5000 daily as supplements. Currently, he only takes ginseng to boost sexual performance.
Allergies: Patient is allergic to latex and mold both cause SOB chest tightening
PMHx: diagnose with hypertension and high cholesterol 10 years ago, left hip replacement 2 years ago. Immunization is up to date.
Soc Hx: Patient works at a call center as a customer service representative for the past thirty years. Married has no children. They live in their two-bedroom mortgage-free house. He currently smokes and has just reduced to 3 cigarettes per day after over forty years of smoking two packs per day. On the weekends he usually goes to the casino with his two college friends to gamble and have a good time. He has no special diet and will eat “anything from anywhere.” Drinks 2 six packs beer per week, and a bottle of vodka on weekends.
Fam Hx: His father died of lung cancer 15 years ago.
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
Head: Symmetrical, no swollen lymph nodes, no signs of sinus infection
Eyes: Does wear glasses due to myopia, no blurred vision, double vision or yellow sclerae.
Ear: No hearing loss.
Nose: Cough present, no congestion, runny nose.
Throat: No sore throat or difficulty swallowing.
SKIN: No rash or itching. Some redness and swelling to right leg.
CARDIOVASCULAR: Right side chest pain, chest pressure, and chest discomfort. Racing heart palpitations.
RESPIRATORY: shortness of breath, chest tightening, increased pain when inhaling, labored breathing.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Some frequency in urination, wakes twice at night to urinate.
NEUROLOGICAL: headaches and numbness and tingling of fingers. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No known history of splenectomy.
PSYCHIATRIC: Endorse feeling anxious
ENDOCRINOLOGIC: reports cold sweat
ALLERGIES: latex and mold
O.
General: steady gait. Flushed face with a facial grimace. Appears anxious
Vital signs:
Temperature: 97.9 oral
Respiratory rate: 32, labored
Heart rate: 112, tachycardic
BP right arm: 148/88
Oxygen saturation: 90% on room air
Weight: 210 lbs., stable
Height: 5’8”
Skin: Cool, diaphoretic
Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds to the left lung
Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur or jugular vein distention.
Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants
Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness
on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
Neurologic: Anxious; awake, alert, and oriented to person, place, and time
Diagnostic results: EKG shows Atrial fibrillation. He is waiting to do an angiography, chest x-ray and a ventilation/perfusion scan (V/Q) to examine blood flow in the lungs. Labs for collection are complete blood count, complete metabolic panel, lipid panel, troponin, creatinine kinase, creatine phosphokinase. D-dimer test to check for DVT and pulmonary embolism are needed, and a cardiac MRI to fully view the heart. (Dains, et al., loc 3494. 2016)
A.
The provider states that the patient may have a pulmonary embolism. While this may be accurate, it is good to rule out other illnesses before giving a definitive diagnosis without proper analysis as misdiagnosis can cause a delay in treatment leading to great consequences. There are other possible differential diagnoses such as GERD, anxiety, and angina; however, listed below are three sudden, life-threatening differential diagnoses listed below.
Differential Diagnoses:
Right side Congestive Heart Failure where according to Ball, Dains, Flynn, Solomon, & Stewart, (2015) the heart is unable to properly pump the blood to the body causing backflow to the lung and congestion in the heart. Hussein, A., & Staufenbiel, R. (2014) noted in their study of 59 cows with heart failures, that with right-sided heart failure the blood venous blood returning to heart is disrupted hence patient ends up with edema to the legs, shortness of breath, increased urination, rapid heartbeat which the patient is currently exhibiting and needs to be further investigated so proper treatment can be done.
Myocardial Infarction occurs due to the heart thickening thus causing decrease blood flow (Ball, et al. p.323. 2016). In Bahall, Seemungal, & Legall, (2018) controlled case study which focused on first time myocardial infarction in the same hospital in Trinidad and their risk factors. The writers look at the risk factors which includes diabetes mellitus, hypertension, hypercholesterolemia, smoking, alcohol consumption, obesity, and sedentary lifestyle, most of which is applicable Mr. H. the writers also reported with myocardial infraction no seen all over the globe therefore region, ethnicity and culture has no bearings on who may fall, victim, especially when they identify with one or more of the listed risk factors.
Pericarditis is when there is an inflamed pericardium due to infection. (Ball, et al. p.322. 2016). Per Dybowska, Kazanecka, Kuca, Burakowski, Czajka, Grzegorczyk, … Tomkowski, (2015) pericarditis is life-threatening and has a high death rate; urgent care is needed to prevent fatalities. While the patient does not have a fever the presentation of pericarditis symptom of chest pain, shortness of breath and chest pressure which the patient presents with should be completely ruled out as soon as possible.
References
Bahall, M., Seemungal, T., & Legall, G. (2018). Risk factors for first-time acute myocardial infarction patients in Trinidad. BMC Public Health, 18(1), 161. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-018-5080-y
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Dybowska, M., Kazanecka, B., Kuca, P., Burakowski, J., Czajka, C., Grzegorczyk, F., … Tomkowski, W. (2015). Intrapericardial fibrinolysis in purulent pericarditis–case report. International Journal of Emergency Medicine, (1), 1. https://doi-org.ezp.waldenulibrary.org/10.1186/s12245-015-0087-y
Hussein, A., & Staufenbiel, R. (2014). Clinical presentation and ultrasonographic findings in buffaloes with congestive heart failure. Turkish Journal of Veterinary & Animal Sciences, 38(5), 534–545. https://doi-org.ezp.waldenulibrary.org/10.3906/vet-1404-111
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Need Response To Below Discussion Post 19339447
/in Uncategorized /by developerAPA format 1 page long 3 references and please include one from discussion post
MSN degree Need ASAP for 9/7/19.
Audience
First-year nursing students come in an associate degree nursing program have typical prerequisite coursework, yet often come with a high degree of variable life experiences. Nursing students, in general, are academic achievers who could not be admitted to their program without a high grade point average. Prerequisite coursework, such as anatomy and physiology, resides at the knowledge and comprehension level of Bloom’s taxonomy, which requires students to explain, memorize, and describe concepts (Bristol & Kerwekh, 2011). Early nursing coursework begins to include application and analysis where students must criticize, compare, and develop ideas. For many, this is a big leap. Bradshaw and Hultquist (2017) describe that students’ progress through learning via set steps. The first step is dualistic thinking where concepts are black and white. This progresses to multiplicity, where more diverse ideas are tolerated. Nursing students also experience a difficult transition to understanding the conceptual grey areas.
Learning Need
Early in the nursing program, students are expected to identify scholarly versus non-scholarly sources of information. Students are expected to include scholarly sources in their self-directed learning and include these in their assignments. Being able to evaluate evidence is critical for patient safety as they advance in their training and career (Horntvedt, Nordsteien, Fermann, & Severinsson, 2018). The following are two learning objectives for this lesson:
Horntvedt et al. (2018) found that interactive teaching and integration into clinical practice were effective strategies for teaching students to evaluate evidence. The learning activity will provide necessary information about scholarly sources of information in an online format. This lesson will use a video presentation to highlight critical concepts related to assessing academic sources of information. During the lesson, students will be shown five different sources of information and be asked to rank the sources in order of most reliable to least reliable.
Evaluation
Shank (2005) emphasizes the need to match the skill level of the learner with the learning objectives and activities. For first-year nursing students, a basic understanding of scholarly versus non-scholarly work is appropriate. An analysis of formal research study validity is beyond the scope of what is needed at their level. The verb summarize corresponds with the knowledge level of learning in Bloom’s taxonomy. The second objective asks the student to provide two examples, which demonstrates comprehension-level understanding in Bloom’s. Both objectives, if successfully met, will allow the student to complete the required work, accessing scholarly work, successfully.
References
Bradshaw, M. J., & Hultquist, B. L. (2017). Innovative teaching strategies in nursing and
related health professions (7th ed.). Burlington, MA: Jones and Bartlett.
Bristol, T. J., & Zerwekh, J. (2011). Essentials of e-learning for nurse educators. Philadelphia,
PA: F. A. Davis Company.
Horntvedt, M.-E. T., Nordsteien, A., Fermann, T., & Severinsson, E. (2018). Strategies for
teaching evidence-based practice in nursing education: a thematic literature review. BMC MEDICAL EDUCATION, 18. https://doi-org.ezp.waldenulibrary.org/10.1186/s12909-018-1278-z
Shank, P. (2005). Writing learning objectives that help you teach and students learn (Part 1).
Online Classroom, 4–7. Retrieved from the Walden Library databases.
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Need Response To Below Discussion Post 19346791
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Online Environment
A significant challenge for online learning environments is to create a sense of community between peers and instructors. One method to achieve this is for instructors to share their authentic selves and stories with their students (Bristol & Zerwekh, 2011). Discussion forums offer the opportunity for instructors and learners to demonstrate their individuality without face-to-face interaction. Andragogy, or the study of adult learning, says that adults learn best when the content is relevant to their lived experience and when there is the opportunity for interaction between peers (Bradshaw & Hultquist, 2017). Relationship building is also crucial for instructor satisfaction, as well. Smith and Crowe (2017) found that instructors were more satisfied when they had the opportunity to get to know their students. For the reasons above, utilization of video presentation of the instructor and use of discussion forum will allow a more personal experience of the online learning environment.
Classroom Management
Nursing students are busy people who juggle many demands at once: family, work, and school, among other things. Students generally do not participate in optional ungraded assignments because of their time constraints (Bristol & Zerwekh, 2011). One strategy for classroom management is to decrease the feeling that students are doing busywork. This requires giving credit, in the form of points toward their grade, for their efforts.
In order to head off problems with netiquette, the nurse educator needs to lie out expectations for interacting in the online environment. This can include basic recommendations such as using a professional writing style that does not include short-hand or abbreviations (Bristol & Zerwekh, 2011). In the online environment, incivility is increasingly a problem that interferes with learning. Social media sites are often the forum for incivility between instructor and student. De Gagne, Yamane, Conklin, Chang, and Kang (2018) recommend implementing policies and guidelines in order to avoid unprofessional conduct in the nursing school environment.
References
Bradshaw, M. J., & Hultquist, B. L. (2017). Innovative teaching strategies in nursing and
related health professions (7th ed.). Burlington, MA: Jones and Bartlett.
Bristol, T. J., & Zerwekh, J. (2011). Essentials of e-learning for nurse educators. Philadelphia,
PA: F. A. Davis Company.
De Gagne, J. C., Yamane, S. S., Conklin, J. L., Chang, J., & Kang, H. S. (2018). Social media
use and cybercivility guidelines in US nursing schools: A review of websites. Journal Of Professional Nursing, 34(1), 35–41. https://doi-org.ezp.waldenulibrary.org/10.1016/j.profnurs.2017.07.006
Smith, Y. M., & Crowe, A. R. (2017). Nurse Educator Perceptions of the Importance of
Relationship in Online Teaching and Learning. Journal of Professional Nursing, 33(1), 11–19. https://doi-org.ezp.waldenulibrary.org/10.1016/j.profnurs.2016.06.004
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Need Response To Below Discussion Post 19396367
/in Uncategorized /by developerAPA format 1 1/2 pages long 3 references 1 from the discussions reference list
due 10/24/19 at 7pm
Incorporating Technology in Community-Based Learning
Unique learning needs exist in all patient populations. However, identifying the need and then designing a technology-based intervention requires a careful analysis of both the population and the planned action. The purpose of this discussion is to describe a community-based population, describe a selected learning need for this population, and explain how I would design a PowerPoint presentation that would address that need.
Community-Based Population
I work in a Federally Qualified Health Center (FQHC) that provides primary care to patients across the lifespan. FQHCs receive funding from the Health Resources and Services Administration Health Center Program to provide care in medically underserved communities (Health Resources & Services Administration [HRSA], 2018). Over 28 million people receive care at FQHCs in the United States (HRSA, n.d.). FQHCs use a sliding scale fee, ensuring patients have access to affordable medical care (HRSA, 2018). While FQHCs are intended to serve the medically uninsured, over 77% of the patients receiving care at FQHCs have private insurance, Medicare, Medicaid, or another governmentally funded health insurance (HRSA, 2019). Females represent 57.65% of the patient population, with patients between the ages of 25 and 69 years old presenting most frequently (HRSA, 2019). However, the FQHC patient population possesses unique barriers to care. A significant hurdle for FQHCs to overcome is language, as 23.63% speak a language other than English (HRSA, 2019). Additionally, 68.23% of the patient population is at or below the poverty level (HRSA, 2019). Complicating continuity of care with this patient population is the high number of migratory and seasonal workers and homeless individuals receiving care (HRSA, 2019). All combined, these factors create a patient population with sub-par health literacy.
Learning Need
Indigent patient populations are more likely to have decreased health literacy levels (Whitley, Jones, Hansen, & Vora, 2019). Additionally, patients with diminished health literacy are less likely to return for follow-up care as scheduled (Thompson et al., 2015). Patients who are chronically under- or uninsured do not return for follow-up appointments as medical is not always viewed as a necessity. Failure to follow-up for appointments as scheduled has been shown to increase emergency department visits and worsen patient outcomes (Arora et al., 2015). Therefore, a means to address the FQHC patients’ knowledge deficit of the need to return for follow-up appointments should be identified and implemented.
Addressing the Learning Need
As previously identified, members of FQHC patient populations have decreased health literacy resulting in noncompliance with follow-up appointments and poorer patient outcomes. However, a systematic review of 60 studies identified text messages as an effective intervention to improve patient compliance, thereby increasing patient outcomes (Hirshberg, Downes, & Srinivas, 2018). Text messages provide a low-cost, highly scalable intervention to improve patient follow-up (Arora et al., 2015). Additionally, few members of society do not have access to a mobile phone. Text messages sent seven days, and one day before scheduled appointments are effective intervals for improving patient follow-up (Arora et al., 2015). Potential obstacles for this intervention include patients changing their mobile numbers, having limited data usage, and the inability to know whether the message was received. However, using text messages to reinforce the need for compliance with follow-up care will address the learning deficit for this patient population. Additionally, orientating the office staff and then including them in the implementation of this intervention will address the staff’s learning need. Therefore, a PowerPoint presentation should be designed to orient the staff to this technology-based, evidence-based intervention.
Summary
Learning needs exist in all patient populations. Ongoing advances in technology are providing new methods for addressing these needs. By taking advantage of these technologies, evidence-based interventions can successfully be implemented in the practice setting.
Reference
Arora, S., Burner, E., Terp, S., Nok Lam, C., Nercisian, A., Bhatt, V., & Menchine, M. (2015). Improving attendance at post–emergency department follow‐up via automated text message appointment reminders: A randomized controlled trial. Academic Emergency Medicine, 22(1), 31-37.
Health Resources & Services Administration. (2018, May 8). Federally Qualified Health Centers. Retrieved from https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html
Health Resources & Services Administration. (2019). 2018 Health Center Data. Retrieved from https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2018&state=
Health Resources & Services Administration. (n.d.). HRSA Health Center Program. Retrieved October 1, 2019, from https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenter factsheet.pdf
Hirshberg, A., Downes, K., & Srinivas, S. (2018). Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: A randomised clinical trial. BMJ Quality & Safety, 27(11), 871-877. doi:10.1136/bmjqs-2018-007837
Thompson, A. C., Thompson, M. O., Young, D. L., Lin, R. C., Sanislo, S. R., Moshfeghi, D. M., & Singh, K. (2015). Barriers to follow-up and strategies to improve adherence to appointments for care of chronic eye diseases. Investigative Ophthalmology & Visual Science, 56(8), 4324-4331. doi:10.1167/iovs.15-16444
Whitley, M. Y., Jones, E. M. V. W., Hansen, B. K., & Vora, J. (2019). The impact of self-monitoring blood glucose adherence on glycemic goal attainment in an indigent population, with pharmacy assistance. Pharmacy and Therapeutics, 44(9), 554. doi:10.43 21/s1885-642×2006000400006
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Need Response To Below Question
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Good observations and I agree. Varied approaches can yield different types of data, all beneficial to evaluating the overall program/program aspects. In your opinion what is one specific method you would recommend to your group, out of those you mentioned?
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Need Response To The Below Discussion
/in Uncategorized /by developerAPA format in a SOAP Note format. 1 page long with questions as to which diagnosis would be accurate and why. I have included the references I need 3 peer review articles to be included
Patient Information:
Initials: JS Age: 11 Sex: M Race: Caucasian
SJ
CC: Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.
HPI: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear. The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.
Current Medications:
1. Ibuprofen 600mg PRN for earache pain
Allergies: NKA
PMHx: Up to date on all immunizations. No significant PMH.
Soc Hx: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer.
Fam Hx: Maternal grandmother died of a stroke at the age of 70. No other significant family history.
ROS:
GENERAL: No fever, fatigue or chills. No weight loss.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears: Patient reporting pain in right ear and hearing loss. Nose, Throat: No sneezing, congestion, runny nose or sore throat.
SKIN: No rashes or itching.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing.
HEENT: PEERLA. Ears: Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact. Nose: Nose is patent without any rhinorrhea. Throat: Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012).
SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good.
RESPIRATORY: LS CTA bilaterally, no sternal retractions noted.
GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present.
NEUROLOGICAL: Cranial nerves II to XII are grossly intact w/out focal neurological defecits (Sullivan, 2012).
LYMPHATICS: No enlarged nodes.
ALLERGIES: No known allergies. No history of asthma, hives, eczema or rhinitis.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Otoscopy: Otoscopy of the ear canal demonstrated erythema, swelling and there was difficulty visualizing the tympanic membrane as there was watery discharge present. According to Lieberthal (2013), otoscopy is usually sufficient enough to reach the diagnosis of otitis externa in children, however, certain cases require additional diagnostics, especially when occurring in infants presenting with fever.
Labs: N/A
A.
Differential Diagnoses:
1. Otitis externa – I chose this as the primary diagnosis because of the patient’s presenting symptoms and the context in which the patient experienced the symptoms. The patient complained of worsening ear pain and hearing loss in the right ear. The patient also reported that he had been swimming in the pool a lot recently. According to Wald (2018), otitis externa often occurs in children after swimming, causes pain and conductive hearing loss if pus or discharge is present and clinical findings include an erythematous, edematous ear canal and difficulty visualizing the tympanic membrane.
usually an infected hair follicle in the ear canal that leads to otalgia and tenderness of the
ear which this patient presented with. However it is not too likely as it usually affects the
cartilage of the year and does not lead to conductive hearing loss (Ibler, 2014).
References
Ibler, K., & Kromann, C. (2014). Recurrent furunculosis – challenges and management:
a review. Clinical, Cosmetic and Investigational Dermatology, 7, 59-64.
doi:10.2147/ccid.s35302
Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson,
M. A., . . Tunkel, D. E. (2013). The diagnosis and management of acute otitis
media. Pediatrics, 131(3), 964-999. Retrieved September 25, 2018, from
http://pediatrics.aappublications.org/content/pediatrics/131/3/e964.full.pdf
Pettigrew, M. M., Gent, J. F., Pyles, R. B., Miller, A. L., Nokso-Koivisto, J., &
Chonmaitree, T. (2011). Viral-bacterial interactions and risk of acute otitis
media complicating upper respiratory tract infection. Journal of Clinical
Microbiology, 49(11), 3750-3755. doi:10.1128/jcm.01186-11
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F.
A. Davis.
Thomas, J. P., Berner, R., Zahnert, T., & Dazert, S. (2014). Acute Otitis Media—a
Structured Approach. Deutsches Ärzteblatt International, 111(9), 151-160.
Retrieved September 25, 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3965963/pdf/Dtsch_Arztebl_Int-
111-0151.pdf.
Wald, E. R. (2018). Acute otitis media in children: diagnosis. UpToDate. Retrieved
September 25, 2018, from https://www.uptodate.com/contents/acute-otitis-media-
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Need Response To This Discussion Post 18997975
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Patient Information:
Mr. H, Age 58, Male, White
S.
CC: Chest Pain “Shortness of breath with severe pain on deep inhalation” (according to Dains, Baumann, & Scheibel, (2016) before a complete HPI is taken this patient must be a quickly assessed as this complaint can have rapid, life-threatening consequences).
HPI: Reports a constant chest pain for two days ago, taking a full breath makes it worst (inhalation), pain is sharp and severe with a current PIS of 8. Subject feel like his heart is racing. Nothing makes the chest pain better. The patient also has exhibited signs and symptoms of a cough, “spit up blood,” right leg swollen and red. He recalls being stationary for an eight-hour period while on a plane, in the economy section middle row, recently from vacationing in Europe, without bathroom overall usually has a sedentary lifestyle mostly due to working 9 am -5 pm as a customer service representative at a call center. After work he sits in front of the television and watches various programs for about four hours while eating dinner, drinking a can of beer or two and smoking a cigarette before bed. It started two days ago when the patient was running to clock in at work, to avoid being late.
Location: right chest pain
Onset: 2 days ago
Character: Sharp and constant
Associated signs and symptoms: a cough, elevated heart rate, and most recently expectoration of blood.
Timing: running to avoid being late for work
Exacerbating/ relieving factors: activity makes it worst. Nothing relieves the pain.
Severity: 8/10 pain scale
Current Medications: Hydrochlorothiazide 25 mg daily for six months, and Norvasc 5 mg twice daily from one month ago for hypertension, Lipitor 80 mg daily for high cholesterol; However, has not been compliant. The patient also stated that he was taking thiamin 100 mg, folic acid 250 mcg and vitamin D 5000 daily as supplements. Currently, he only takes ginseng to boost sexual performance.
Allergies: Patient is allergic to latex and mold both cause SOB chest tightening
PMHx: diagnose with hypertension and high cholesterol 10 years ago, left hip replacement 2 years ago. Immunization is up to date.
Soc Hx: Patient works at a call center as a customer service representative for the past thirty years. Married has no children. They live in their two-bedroom mortgage-free house. He currently smokes and has just reduced to 3 cigarettes per day after over forty years of smoking two packs per day. On the weekends he usually goes to the casino with his two college friends to gamble and have a good time. He has no special diet and will eat “anything from anywhere.” Drinks 2 six packs beer per week, and a bottle of vodka on weekends.
Fam Hx: His father died of lung cancer 15 years ago.
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
Head: Symmetrical, no swollen lymph nodes, no signs of sinus infection
Eyes: Does wear glasses due to myopia, no blurred vision, double vision or yellow sclerae.
Ear: No hearing loss.
Nose: Cough present, no congestion, runny nose.
Throat: No sore throat or difficulty swallowing.
SKIN: No rash or itching. Some redness and swelling to right leg.
CARDIOVASCULAR: Right side chest pain, chest pressure, and chest discomfort. Racing heart palpitations.
RESPIRATORY: shortness of breath, chest tightening, increased pain when inhaling, labored breathing.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Some frequency in urination, wakes twice at night to urinate.
NEUROLOGICAL: headaches and numbness and tingling of fingers. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No known history of splenectomy.
PSYCHIATRIC: Endorse feeling anxious
ENDOCRINOLOGIC: reports cold sweat
ALLERGIES: latex and mold
O.
General: steady gait. Flushed face with a facial grimace. Appears anxious
Vital signs:
Temperature: 97.9 oral
Respiratory rate: 32, labored
Heart rate: 112, tachycardic
BP right arm: 148/88
Oxygen saturation: 90% on room air
Weight: 210 lbs., stable
Height: 5’8”
Skin: Cool, diaphoretic
Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds to the left lung
Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur or jugular vein distention.
Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants
Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness
on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
Neurologic: Anxious; awake, alert, and oriented to person, place, and time
Diagnostic results: EKG shows Atrial fibrillation. He is waiting to do an angiography, chest x-ray and a ventilation/perfusion scan (V/Q) to examine blood flow in the lungs. Labs for collection are complete blood count, complete metabolic panel, lipid panel, troponin, creatinine kinase, creatine phosphokinase. D-dimer test to check for DVT and pulmonary embolism are needed, and a cardiac MRI to fully view the heart. (Dains, et al., loc 3494. 2016)
A.
The provider states that the patient may have a pulmonary embolism. While this may be accurate, it is good to rule out other illnesses before giving a definitive diagnosis without proper analysis as misdiagnosis can cause a delay in treatment leading to great consequences. There are other possible differential diagnoses such as GERD, anxiety, and angina; however, listed below are three sudden, life-threatening differential diagnoses listed below.
Differential Diagnoses:
Right side Congestive Heart Failure where according to Ball, Dains, Flynn, Solomon, & Stewart, (2015) the heart is unable to properly pump the blood to the body causing backflow to the lung and congestion in the heart. Hussein, A., & Staufenbiel, R. (2014) noted in their study of 59 cows with heart failures, that with right-sided heart failure the blood venous blood returning to heart is disrupted hence patient ends up with edema to the legs, shortness of breath, increased urination, rapid heartbeat which the patient is currently exhibiting and needs to be further investigated so proper treatment can be done.
Myocardial Infarction occurs due to the heart thickening thus causing decrease blood flow (Ball, et al. p.323. 2016). In Bahall, Seemungal, & Legall, (2018) controlled case study which focused on first time myocardial infarction in the same hospital in Trinidad and their risk factors. The writers look at the risk factors which includes diabetes mellitus, hypertension, hypercholesterolemia, smoking, alcohol consumption, obesity, and sedentary lifestyle, most of which is applicable Mr. H. the writers also reported with myocardial infraction no seen all over the globe therefore region, ethnicity and culture has no bearings on who may fall, victim, especially when they identify with one or more of the listed risk factors.
Pericarditis is when there is an inflamed pericardium due to infection. (Ball, et al. p.322. 2016). Per Dybowska, Kazanecka, Kuca, Burakowski, Czajka, Grzegorczyk, … Tomkowski, (2015) pericarditis is life-threatening and has a high death rate; urgent care is needed to prevent fatalities. While the patient does not have a fever the presentation of pericarditis symptom of chest pain, shortness of breath and chest pressure which the patient presents with should be completely ruled out as soon as possible.
References
Bahall, M., Seemungal, T., & Legall, G. (2018). Risk factors for first-time acute myocardial infarction patients in Trinidad. BMC Public Health, 18(1), 161. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-018-5080-y
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Dybowska, M., Kazanecka, B., Kuca, P., Burakowski, J., Czajka, C., Grzegorczyk, F., … Tomkowski, W. (2015). Intrapericardial fibrinolysis in purulent pericarditis–case report. International Journal of Emergency Medicine, (1), 1. https://doi-org.ezp.waldenulibrary.org/10.1186/s12245-015-0087-y
Hussein, A., & Staufenbiel, R. (2014). Clinical presentation and ultrasonographic findings in buffaloes with congestive heart failure. Turkish Journal of Veterinary & Animal Sciences, 38(5), 534–545. https://doi-org.ezp.waldenulibrary.org/10.3906/vet-1404-111
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