Case Study 1
Learning Goal: I’m working on a nursing case study and need an explanation and answer to help me learn.
|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.|
|Subjective||denies 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.|
|General||patient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs|
|HEENT||EYES: 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
|Respiratory||lung 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/Throat||no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
|Heart||Regular rate and rhythm, no murmur, S3, or S4|
Answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
- Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.