Healthcare -- Nursing -- Case Study I am required to make differential diagnosis, examine health issues and their management, order diagnostic tests and provide health teachings/health promotion for "Ted." Ted is a 55-year-old Caucasian man with general malaise and a 6-day history of a productive cough. During this time he had noticed a gradual accumulation of fluid in his legs and feet. He had not seen a health care professional in 3 years. His social history was significant because he smoked about a pack of cigarettes a week. Ted reported having a dry, hacking cough for years, but he attributed it to 30 years of smoking. The review of systems was unremarkable. Generally he appeared well nourished and in no acute distress. The physical exam showed the following: weight 142 pounds, height 5'8," blood pressure 150/92 mmHg left arm and 158/96 mmHg right arm, temperature 99.2 degrees F, and oxygen saturation 97% on room air, dropping to 96% on ambulation.

Abnormal findings on exam included bibasilar crackles and coarse wheezing throughout all fields, with signs of focal consolidation on the right. Bilateral anterior cervical and supraclavicular lymphadenopathy were present. He had a III/VI holosystolic murmur and an S4 gallop, which were new findings compared with his last exam. Limb examination found 3+ bilateral lower extremity brawny edema, but there was no warmth, erythema or tenderness. Homan's sign was negative.

Ted's electrocardiogram (ECG) was within normal limits, and I ordered a chest film for the following day. Based on the history and physical findings, I treated Ted empirically...

A follow-up visit was scheduled for 48 hours later. The initial medical plan included respiratory treatments, azithromycin (Z-Pac) as directed, and hydrochlorothiazide (HCTZ) 25 mg four times a day.
B. Body

1. Differential Diagnosis

Given Ted's chief complaints, history and physical examination, I would consider and rule out: pneumonia; neoplastic disease (lung cancer); congestive heart failure; cardiovascular disease; COPD; and emphysema (Jensen & Rhoads, 2014, pp. 37-46, 191-197).

2. Ted's Health Issues and Their Management

Ted's health issues include: his age; general malaise; a 6-day history of a productive cough; gradual accumulation of fluid in his legs and feet; social history of smoking for 30 years at the rate of about a pack of cigarettes a week; dry, hacking cough for years; bibasilar crackles and coarse wheezing throughout all fields, with signs of focal consolidation on the right; bilateral anterior cervical and supraclavicular lymphadenopathy; III/VI holosystolic murmur and S4 gallop, new findings compared with his last exam; and 3+ bilateral lower extremity brawny edema, but there was no warmth, erythema or tenderness. These indicate the possibilities of: pneumonia (Ackley & Ladwig, 2014, p. 42); neoplastic disease (lung cancer) (Ackley & Ladwig, 2014, p. 37); congestive heart failure (Ackley & Ladwig, 2014, p. 37); cardiovascular disease (Ackley & Ladwig, 2014, pp. 122-3); COPD (Ackley & Ladwig, 2014, pp. 122-3); and emphysema (Ackley & Ladwig, 2014, pp. 122-3).

I am…