Pericarditis

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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.  

Shortness of breath

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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.    

Acute bronchitis

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Diagnostics:

  1. Chest X-ray: helps your doctor diagnose pneumonia and determine the extent and location of the infection (Mayo Clinic, 2018).

 Differential Diagnoses:

  1. Bacterial pneumonia: is an infection of the air sacs in one or both lungs which may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing, dullness to percussion, decreased breath sound, fatigue. It is most commonly caused by Streptococcus pneumoniae(Mayo Clinic, 2018). Since the patient appears to have most of these symptoms, this is a great possibility.
  2. Acute bronchitis: Acute bronchitis, often called a “chest cold,” is the most common type of bronchitis. It occurs when the airways of the lungs swell and produce mucus which makes one cough. It is caused by a virus and often occurs after an upper respiratory infection. Symptoms include sore throat, soreness in the chest, fever, coughing with or without mucus production, fatigue, mild headaches and watery eyes (CDC, 2017b). This can also be a possibility based on the patient’s symptoms.
  3. Asthma exacerbation: Asthma is a disease that affects your lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing. Asthma can be controlled by taking medicine and avoiding the triggers that can cause an attack (CDC, 2017a). This can also be a possibility based on the patient’s symptoms.
  4. Bronchiectasis exacerbation: Bronchiectasis is a condition in which the airways (called bronchial tubes) that branch from the trachea into each lung become widened and inflamed. Such damage limits the ability of the airways to clear bacteria and mucus from the lungs, resulting in sputum production, cough, and shortness of breath. Bronchiectasis can be congenital or acquired as a result of an infection. Symptoms include cough, shortness of breath, wheezing, weight loss, fatigue and chronic sinusitis (Mount Sinai, 2018). Based on these symptoms, this can be a possibility for patient diagnosis.
  5. COPD exacerbation: chronic obstructive pulmonary disease (COPD) experiences long-term and progressive damage to their lungs. This affects air flow to the lungs. Symptoms include rapid shallow breathing, increasing amounts of mucus, which is often yellow, green, tan, or even blood-tinged, experiencing shortness of breath at rest or with minimal activity, such as walking from one room to another and wheezing more than usual (Healthline.com, 2018). Based on patient symptoms, this can also be a possibility for the patient condition.

References

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.

Centers for Disease Control and Prevention (2017a). Asthma. Retrieved October 9, 2018 from:

Centers for Disease Control and Prevention (2017b). Bronchitis. Retrieved October 9, 2018

from: https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/bronchitis.html

Healthline.com (2018). COPD Exacerbation. Retrieved October 9, 2018 from:

Laureate Education. (Producer). (2012). Advanced health assessment and diagnostic reasoning.

Baltimore, MD: Author.

Mayo Clinic (2018). Pneumonia. Retrieved October 9, 2018 from:

Mount Sinai (2018). What is Bronchiectasis? Retrieved October 9, 2018 from:

Review of Systems

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General: productive cough with green phlegm and blood at times; shortness of breath, chills, night sweats, fever and restlessness.

HEENT: Patient denies head or nasal congestion, headache, nasal discharge, dizziness, vertigo. Patient states productive cough with green-colored sometimes bloody phlegm.

Cardiovascular: Patient denies palpations. Has some chest tightness.

Respiratory: Patient states that he has SOB that worsens with walking. Has productive cough with green-colored sputum and occasional hemoptysis. Patient states that he hears whistling noises when he breathes.

Objective Data:

Physical exam:

General: Mr. Hendricks is a 60 year old Caucasian male and a good historian who is relatively healthy and has good hygiene. Alert and oriented x 3, looks age appropriate with normal facial expression and appropriate behavior. He coughed a few times during exam and appears to be in some respiratory distress with shortness of breath.

Vital signs: Ht. 5’9”, Wt. 210 lbs; BMI= 30, blood pressure 128/70, pulse of 82, respirations of 20 and labored, temperature of 100.9 and O2 saturation on room air of 89%.

HEENT: No headache or head masses. No lesions. Wears glasses. Pupils equal and reactive to light; ears symmetrical, no tenderness or discharge. No frontal or maxillary sinus tenderness. No discharge from nose and mucosa pink and moist. Wears partial upper dentures. Throat appears red. Good hygiene.

Neck: No masses, full range of motion. Thyroid size normal.

Integumentary: Warm and most

Respiratory: Thorax symmetrical with diminished breath sounds. B/L rales and expiratory wheezes throughout. Wet productive cough.

Cardiovascular: regular heart rate with good S1 and S2 heart sounds. No S3, S4 or murmur.

Gastrointestinal: abdomen protuberant. Normoactive bowel sounds in all four quadrants.

Peripheral vascular: No peripheral edema. 2+ dorsalis pedis pulses palpated bilaterally.

ASSESSMENT:

Lab Tests and Results:

  1. CBC: Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection (Mayo Clinic, 2018.)
  2. Sputum culture: is taken after a deep cough and analyzed to help pinpoint the cause of the infection (Mayo Clinic, 2018).
  3. O2 saturation: decreased oxygen saturation indications indicates hypoxemia. Normal range should be 95-100% on RA (Mayo Clinic. 2018).

coughs

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APA format 3 peer review references due 10/13/18 at 2pm EST 

Patient Initials: __JH_____                Age: __60_____                                 Gender: ____M___

Subjective Data:

Chief Complaint: Case #3 “I have a cough that’s getting worse.” (Laureate Education, 2012).

HPI: Mr. Hendricks is a 60 year-year old Caucasian male who presents today complaining of a cough that is progressively getting worse; more frequent over the past three days. He states that his cough is accompanied by expectoration of thick green secretions accompanied by some blood at times. He has associated symptoms of shortness of breath that is aggravated when walking and nothing seems to help. Patient also states that he had difficulty trying to fall asleep last night because he felt like he was getting a fever and had intermittent chills and sweats and took Tylenol. He states “I have never felt like this before and would like to know what’s going.”

Medications: over the counter Tylenol 650mg po at nights.

Allergies: No known drug or food allergies. No seasonal allergies.

Past Medical History: No medical history provided.

Past Surgical History: No surgical history provided.

Immunization history: Up to date with immunizations. Influenza shot received September 2018. Pneumococcal vaccine received October 2018.

Personal/Social History: Patient denies smoking, drinks wine socially, exercise with brisk walking three times weekly and tries to eat a balanced diet. He has a master’s degree in finance and works as an accountant at an accounting firm. He is a safe driver who drives to work daily and always wears seatbelt. He lives with his wife who is a homemaker who helps baby sit twin granddaughters. Patient denies history of recent travel to foreign country within the three months.

role of the DNP-prepared nurse

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Discuss the role of the DNP-prepared nurse in sustaining an EBP culture. What are two effective methods the DNP can use in sustaining an EBP culture?

model for EBP implementation

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Choose one model for EBP implementation. Describe its components and why you believe this model is most appropriate for assisting in translational activities. Contrast this model with another.

Medications errors.

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A medication error is a preventable adverse effect of a patient taking the wrong medication or dosage, whether or not it is evident or harmful to the patient. Medication errors can be a source of serious patient harm, including death

Limited Access to Healthcare.

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Topic 1-Limited Access to Healthcare.

(Consumers face barriers to healthcare access for assorted reasons. For example: due to geographic location, provider availability, transportation issues and mobility.)

Respiratory Tract Infections, Neoplasms, and Childhood Disorders

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Patricia was called at work by a woman at the local daycare center. She told Patricia to come and pick up her son because he was not feeling well. Her son, three-and-a-half-year-old Marshall, had been feeling tired and achy when he woke up. While at daycare, his cheeks had become red and he was warm to touch. He did not want to play with his friends, and by the time Patricia arrived, he was crying. Later that afternoon, Marshall’s condition worsened. He had fever, chills, a sore throat, runny nose, and a dry hacking cough. Suspecting Marshall had influenza, Patricia wrapped him up and took him to the community health care clinic.

  1. Why did Marshall’s presentation lead Patricia to think he had influenza and not a cold? Why is it important to medically evaluate and diagnose a potential influenza infection?
  2. Describe the pathophysiology of the influenza virus. Outline the properties of influenza A antigens that allow them to exert their effects in the host.
  3. Marshall may be at risk at contracting secondary bacterial pneumonia. Why is this so? Explain why cyanosis may be a feature associated with pneumonia.