Wk3 NR 511 Part1 Assignment

Wk3 NR 511 Part1 Assignment

Wk3 NR 511 Part1 Assignment

Katie
CC: “Cough that is not getting better, tired and easily winded on walks,”

HPI:
Onset: One week ago, what prompted the cough? Is there a seasonal pattern? Is it related to environmental irritants?

Location: not specified: Do you have post nasal drip? Does the cough feeling like its coming from your throat or chest?
Duration: Worse at night. How frequent are you coughing? Have you ever had these symptoms before?  If so how often?
Characteristics: Tired and easily winded: How would you describe your cough; hacking, dry, barking, hoarse, congested, wet, raspy, deep or throaty? Is it productive or unproductive? How much sputum do you cough up in a day? Up to a table spoon or more? Is the color yellow, blood tinged, gray, green, brown, clear or white? Is the sputum frothy, thick, ropy or tenacious. When are you most productive? Do you cough more when lying down?

 

Aggravating factors: not specified: Is there anything that makes your cough worse? Does talking, activity, or position change make your cough worse?

 

Relieving factors: not specified: Have you tried anything to relieve your cough such as lozenges, hot tea, sipping hot water and using humidifier? Does resting or sitting calmly help with the cough?

Wk3 NR 511 Part1 Assignment

Treatment: not specified: What treatments have you tried? Have you taken prescription or OTC medications? Aside from HCTZ what other blood pressure medication are you taken?

 

Severity: Unable to exercise due to profound weakness and insomnia. Tell me what you mean by you are easily winded? On a scale of 1-10 rate the level of your discomfort with the cough? How is your breathing?

ROS: Additional questions that I would ask:

 

CONSTITUTIONAL: Weakness and fatigue present, no chills, nausea, vomiting, night sweats weight loss or gain?

HEENT:

Head Do you have a headache?

Eyes Do you have watery or purulent drainage from your eyes?

Ear: Do you have ear pain or drainage in the ear?
Nose: Do you have nasal congestion or sinus pressure? Did have runny nose or allergies prior to having cough?

Throat: Do you feel any sensation in your throat?  Any swelling or neck stiffness? Do you have swollen lymph nodes?
CARDIOVASCULAR: Any chest tightness, pain, heaviness, palpitations, or irregular heart rate?
RESPIRATORY: Any shortness of breath or hard-breathing with exertion? Any Wheezing? How much sputum do you produce in a day? What is the color and texture of it?  Do you get frequent respiratory infections? Have you ever had an asthma attack, pneumonia or bronchitis? Is it difficult to breathe when lying down? Do you feel like you can’t “Catch” your breath sometimes?

Wk3 NR 511 Part1 Assignment

ABDOMINAL: Have you had any nausea, vomiting, abdominal pain, changes in appetite?
LYMPHATICS: Do you have any pain or tenderness in your neck? Swollen lymph nodes?

 

DIFFERENCIALS:
Community Acquired Pneumonia (CAP) (IDC-10: J18.9): Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae viruses are the most common viral cause of community acquired pneumonia (Kaysin & Viera, 2016). CAP is a leading cause of death with risk factors that include advanced age, immunocompromised state, and medical comorbidities (Kaysin & Viera, 2016). Pneumonia manifests with persistent symptoms of cough, tachypnea, tachycardia, chest pain, headache, myalgia, and malaise for more than three to five days (Tan et al., 2016). The symptoms may worsen with time, and signs and symptoms such as dyspnea and cyanosis can appear (Tan et al., 2016).

Bronchitis IDC-10: J20.4): Is an inflammation of the bronchial tubes, the large airways leading from the throat into the lungs (Holzinger et al., 2014). This common condition causes a cough that produces mucus. Viruses are the most common cause of bronchitis, but it can also be caused by bacteria (Holzinger et al., 2014). Signs and symptoms include cough, pain or discomfort, shortness of breath, fatigue, fever, tightness, sore throat (Hollier, 2016; Holzinger et al., 2014).

Asthma (IDC-10: J45.20): Asthma is a chronic inflammatory airway disorder where mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, epithelial cells, and other cellular elements all play a role in the development of inflammation (Broders, Desai, & Wilson, 2013). In patients with asthma signs and symptoms may include: recurrent wheezing episodes, breathlessness, chest tightness, and coughing, especially at night or early in the morning, may occur because of this inflammation. (Broders et al., 2013).

Congestive Heart Failure (IDC-10: I11.0): Is a cardiac disease associated with the decreasing capacity of the hearts output (Lucena, Barros, & Ohnishi, 2016). Beit left, right or both sides of the heart is unable to meet the metabolic demands of the body (Lucena et al, 2016). Mild and moderate signs and symptoms include dyspnea on exertion, tachycardia, diminished exercise capacity, fatigue and/or weakness, peripheral edema, weight gain, and nocturnal cough (Goroll & Mulley, 2014; Lucena et al, 2016).

What focused PE would you perform? What labs or diagnostic tests, if any, would you order? Is there any point of care testing for these differentials?

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