Subjective Data: To create a comprehensive health history for this patient, I would collect more subjective data, such as the following:
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Cough onset, duration, and pattern
The presence of any sputum production, as well as its color, quantity, and consistency
Shortness of breath, chest tightness, or chest pain. Any history of smoking, irritant exposure in the environment, or previous respiratory infections
Any previous medical history concerning COPD or other respiratory conditions
Any medications the patient is currently taking, as well as any medication allergies
Any previous hospitalizations or ER visits for respiratory symptoms
I would perform the following evaluations in addition to the objective findings noted in the patient’s presentation:
Complete physical examination, including chest, abdomen, and extremities.
Examine the patient for clubbing or cyanosis and any chest deformities or signs of a barrel chest.
Examine for wheezing or stridor.
Check for any additional sounds, such as crackles, wheezes, or rhonchi.
To assess lung function, measure forced expiratory volume (FEV1) and forced vital capacity (FVC).
Examination for Diagnosis:
I would order the following diagnostic tests based on the patient’s presenting symptoms and physical examination findings:
X-ray of the chest to look for any underlying structural abnormalities in the lungs, such as pneumonia or atelectasis.
ABG (arterial blood gas) analysis to detect hypoxia or hypercapnia
A complete blood count (CBC) is performed to rule out any underlying infection.
Spirometry is used to assess lung function and the severity of COPD.
The following are three differential diagnoses based on the patient’s presenting symptoms:
Acute exacerbation of COPD (AECOPD) Rationale: AECOPD is a common COPD complication that manifests as a persistent cough, increased sputum production, and shortness of breath. This diagnosis is supported by crackles in the lower lung fields and dullness to percussion over the LLL.
Pneumonia Rationale: Pneumonia can cause symptoms similar to AECOPD, such as coughing, fever, and increased respiratory effort. This diagnosis is supported by the presence of bilateral erythema and edema of the turbinates with yellow drainage, as well as the patient’s appearance of being tired and diaphoretic.
Bronchitis Rationale: Bronchitis symptoms include cough, increased sputum production, and shortness of breath, similar to AECOPD and pneumonia. This diagnosis is supported by the presence of crackles in the lower lung fields, as well as the patient’s history of COPD.
In conclusion, the patient’s symptoms and objective findings suggest AECOPD, pneumonia, or bronchitis. Additional diagnostic evaluations and assessments are required to determine the specific diagnosis and guide treatment.
Chronic Obstructive Lung Disease Global Initiative (2021). Global strategy for chronic obstructive pulmonary disease diagnosis, management, and prevention. COPD IN GOLD.
K. F. Rabe, S. Hurd, A. Anzueto, P. J. Barnes, S. A. Buist, P. Calverley,… H. Magnussen (2021). Report on the global strategy for diagnosing, managing, and preventing chronic obstructive pulmonary disease (COPD) in 2021. European
For this, you will take on the role of a clinician who is building a health history for the following patient:
(CC) A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents to the clinic with a cough he has had for the past 2 weeks.
Subjectivedenies chest pain, denies night sweats, admits to having a fever but does not know the temp.
VS(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air.
Generalpatient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs
HEENTEYES: no injection, no increase in lacrimation or purulent drainage;
NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Obstructed air passages
Respiratorylung crackles in LLL, no wheezes or rhonchi noted; does not clear with coughing; dullness to percussion over the LLL; shallow respirations and is 30, accessory muscles use not present
Neck/Throatno neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
HeartRegular rate and rhythm, no murmur, S3, or S4
Answer the following :
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic examination do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.
Requirements: at least 500 words ( 2 complete pages of content) formatted and cited in current APA style 7 ed with support from at least 3 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 5%.