How would the treatment plan change if the client admitted
How would the treatment plan change if the client admitted to food insecurity? What resources are available in (columbus, ohio) community that would be useful for senior citizens experiencing food insecurity and dietary restrictions based on medical diagnoses?
Including the following components:
demonstrate clinical judgment appropriate to the virtual patient scenario, one fifty to three hundred words included
cite at least one relevant scholarly source
Differential diagnosis (DDx): Whats most appropriate differential diagnoses for the encounter?
Differential diagnosis ranking: Rank the differential as lead and alternate diagnoses
Must Not Miss: Identify the must not miss (MNM) diagnoses
Diagnostic tests: What are the appropriate diagnostic tests for the virtual patient.
Chris Alvarez is a 72-year-old male presenting with a chief complaint of shortness of breath (SOB). His medical history includes hypertension, hyperlipidemia, smoker. This essay will focus on the patient’s physical and mental workup, Medical Subject Access Protocol (MSAP), diagnosis, differential diagnosis, and problem statement, as well as a SOAP note summarizing the patient’s course of care.
Explanation:
Initial Physical and Mental Workup
On initial assessment, Mr. Alvarez is a frail appearing man in moderate distress. He is alert and oriented x3, with no acute distress apparent on extra-ocular motion assessment. He has a pulsatile-appearing chest, but no wheezing or rhonchi are auscultated. His respiration rate is 24 per minute, with oxygen saturation of 99% on room air. He is afebrile with an oral temperature of 98.6 Fahrenheit, heart rate 114 beats per minute, and blood pressure of 160/90mmHg. He does not appear to be in pain when palpated in his chest or abdomen.
Mental status and cognitive assessment reveals that Mr. Alvarez is oriented to person, place, and time. He appears to have intact language and memory skills, as well as judgment. His initial score on mini-mental status exam is 28 out of 30.
Medical Subject Access Protocol (MSAP)
Due to the chief complaint of SOB, the medical subject access protocol that should be conducted is an X-ray of the chest. This will enable the medical team to evaluate the lungs and assess the presence of any pathologic processes that could be contributing to the patient’s manifestations. The physician should also order blood tests (complete blood count, electrolytes, and coagulation profile), a cardiopulmonary stress test, and an electrocardiogram. Additional testing may include echocardiogram or bronchoscopy if deemed necessary, depending upon the results of the workup already ordered.
Diagnosis
Based on the patient’s presentation and the results of the medical workup, the patient was diagnosed with shortness of breath of cardiac origin with underlying congestive heart failure. The X-ray revealed B lines, with bilateral basal infiltrate, suggesting congestive heart failure (CHF). The blood workup showed a rise in serum creatinine levels indicating renal insufficiency, as well as elevated BNP levels, confirming the diagnosis of CHF. The findings of the echocardiogram revealed an ejection fraction of 25%, known as Class II CHF.
Differential Diagnosis
The differential diagnosis of the patient included blood clots, asthma, and COPD. These processes have similar symptoms but differ in their etiology and treatments. Blood clots are typically caused by an interruption of the blood flow, which could lead to pulmonary embolism, resulting in SOB. Asthma is an inflammatory process of the lungs, which can cause difficulty in expelling air and result in SOB. COPD is caused by long term irritation of the airway leading to chronic inflammation and obstruction of airflow, resulting in SOB.
Problem Statement
Mr. Alvarez is a 72-year-old male suffering from shortness of breath caused by congestive heart failure.
SOAP Note
SUBJECTIVE:
Mr. Alvarez is a 72-year-old male presenting with a chief complaint of shortness of breath. His past medical history includes hypertension, hyperlipidemia, and smoking history.
OBJECTIVE:
On initial assessment, Mr. Alvarez is alert and oriented x3, with no acute distress apparent on extra-ocular motion assessment. His respiration rate is 24 per minute, with oxygen saturation of 99% on room air. He is afebrile with an oral temperature of 98.6 Fahrenheit, heart rate 114 beats per minute, and blood pressure of 160/90mmHg. The X-ray revealed B lines, with bilateral basal infiltrate, suggesting congestive heart failure. The blood workup showed a rise in serum creatinine levels indicating renal insufficiency, as well as elevated BNP levels, confirming the diagnosis of CHF. The findings of the echocardiogram revealed an ejection fraction of 25%, known as Class II CHF.
ASSESSMENT:
Based on the patient’s presentation and medical workup, the patient is diagnosed with shortness of breath of cardiac origin with underlying congestive heart failure (CHF).
PLAN:
The plan of care includes medications to manage CHF, such as diuretics and beta-blockers. In addition, lifestyle modifications such as smoking cessation and dietary restrictions should be emphasized. The patient should also be educated on signs and symptoms of worsening CHF. Follow up with a pulmonologist and cardiologist should be scheduled for further management.
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