Differential Diagnosis and Treatment for Several Possible Maladies

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 for pneumonia and hypertension. 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 monitoring Ted's health issues by: ordering a chest film for the following day; treating him empirically for pneumonia and hypertension; scheduling a follow-up visit for 48 hours later; respiratory treatments; azithromycin (Z-Pac) as directed; and hydrochlorothiazide (HCTZ) 25 mg four times a day.

In addition, I will: monitor his intake/output of fluids; educate him about diet and place him on a low sodium diet; educate him about smoking effects on his cardiovascular system, increased risk of stroke, cancer, and heart attack; educate him about the benefits of exercise; educate him about preventive care, such as regularly seeing a doctor; educate him about the effects of lifestyle on hypertension and the links between hypertension and artery damage and narrowing, aneurisms, coronary artery disease, heart enlargement, heart failure, heart attack, stroke, cognitive impairment and dementia; monitor and record his TPR (temperature, pulse, respiration); monitor his productive cough; collect a culture for culture sensitivity; elevate his head; elevate his legs; monitor his activity; monitor his arterial blood gas; and weigh him frequently to assist in monitoring his edema (Jensen & Rhoads, 2014, pp.

37-46, 191-197). I would also anticipate that the doctor will order oxygen, chest X-ray and sputum for culture sensitivity. 3. Diagnostic Tests I will request: blood cultures; sputum culture; urinalysis; CBC with differential; and electrolytes (Jensen & Rhoads, 2014, pp. 37-46, 191-197). I would also anticipate that the doctor will order a chest X-ray. 4.

Health Teachings/Health Promotion My health teachings/health promotion in this case will include: diet, particularly a low-sodium diet; smoking effects on his cardiovascular system, increased risk of stroke, cancer, and heart attack; the benefits of exercise; preventive care, such as regularly seeing a doctor; and the effects of lifestyle on hypertension and the links between hypertension and artery damage and narrowing, aneurisms, coronary artery disease, heart enlargement, heart failure, heart attack, stroke, cognitive impairment and dementia.