homework

Based on the information attached I need to analyze the data and find the diagnostic and 3 possible differential diagnostic. Explain why I arrived to this conclusion using the form attached

CASE STUDY WORKSHOP 2

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Based in the following information analyze the data and find the diagnostic and 3 possible differential diagnoses

This is a follow-up visit….

This is a 66-years-old male; with PMH of CAD diagnosed patient with stent inserted in 2010; carotid artery disease with stent 1999; aortic stenosis; CVA 1998. Additionally, he is DM Type 2 and had a colon cancer condition with resection in 2011. Mr. M.L is a Retired Veteran, who lives with wife and 2 dogs. The wife has MS, and he is the caregiver for her. Rarely drinks ETOH; smokes since teenage years.

The day of his visit the V/S were BP 165/98 mmHg; Height: 5’10”; weight 208 lbs; BMI 29.8 kg/m2; HR 64/min; RR 23 per minute; Temperature 97.5 °F.

Patient takes usual secondary prevention medications: ASA 81 mg; Simvastatin 40 mg; Clopidogrel 75 mg; Losartan HCTZ 50-12.5 mg; Metoprolol XL 25 mg; Amlodipine 5 mg; Metformin 1,000 mg; Omeprazole; Prilosec OTC

The last laboratory test: Lipid panel: TC 156, TG 209, HDL 47, LDL 67 mg/dL; Hemoglobin A1C 6.3% .

Reports eating “only organic” foods; walks dogs twice a day; swims in backyard pool during the summer and expresses that he is NOT interested in quitting smoking. When addressing the effects of secondhand smoke on his wife, he responded, “Then she shouldn’t have married me!”

The patient reports that he is fatigued since this Chicago winter. He uses a snow blower however he also uses a shovel. Lately when its subzero, he feels shorter of breath walking his dogs. He has felt some indigestion when shoveling snow. He started to double Prilosec OTC however the indigestion goes away in several minutes after he stops shoveling snow. He isn’t sure if he has arm pain as well because his left arm gets sore from shoveling snow. Denies palpitations, lightheadedness, syncope, and claudication.

On physical examination, patient looks fine. Lungs clear, but he become with SOB after a short activity. Continues with pain in Left Arm that irradiates to the jaw and the thorax. Mr. M.L. states he feels fainting, but states that the shoveling duties are the reason of that feeling.

Instruction

Based in the information provided fill it out the following two form and find the possible 3 differential diagnoses

1-Data analysis and working sheet

2- Soup note

Use the from “Data analysis and working sheet” This form guides step by step the establishment of differential diagnoses.

Use the soup note form to complete the activity

PRIMARY

CARE SOAP NOTE

PRIMARY CARE SOAP NOTE

Student: __________________________ Date: ______________

Professor: ______________________________________________________________

PATIENT INFORMATION:

NAME: ______________________________________________________________________

AGE: ______________SEX: _______________

CC:__________________________________________________________________________

______________________________________________________________________________

SUBJECTIVE:

HPI:_________________________________________________________________________

______________________________________________________________________________ ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ ______________________________________________________________________________

______________________________________________________________________________

ALLERGIES:

______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

CURRENTMEDICATIONS_____________________________________________________

______________________________________________________________________________

PMHX:_______________________________________________________________________

FAMH:_______________________________________________________________________

SOCHX:______________________________________________________________________

REVIEW OF SYSTEMS:

CONSTITUTIONAL:__________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ ______________________________________________________________________________

______________________________________________________________________________

HEENT:

HEAD:_______________________________________________________________________

EYES:________________________________________________________________________

EARS:_______________________________________________________________________

NOSE:_______________________________________________________________________

THROAT:____________________________________________________________________

RESPIRATORY:

______________________________________________________________________________

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL: _______________________________________________________

NEUROLOGIC:_______________________________________________________________

______________________________________________________________________________ ______________________________________________________________________________ OBJECTIVE:

CONSTITUTIONAL:

SKIN:

______________________________________________________________________________

HEENT:

NECK:

______________________________________________________________________________

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

______________________________________________________________________________ GENITOURINARY:

PERIPHERAL VASCULAR:

MUSCULOSKELETAL:

NEUROLOGIC:

ASSESSMENT:

DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS:

______________________________________________________________________________

______________________________________________________________________________ ____________________________________________________________________________ PLAN:

______________________________________________________________________________

________________________________________________________________________

Non-Pharmacologic treatment:

______________________________________________________________________________ ______________________________________________________________________________

______________________________________________________________________________ Pharmacologic treatment:

MEDICATIONS:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

FOLLOW-UPS/REFERRALS:

______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Diagnostic & Differential Diagnosis (Nurs 508)

Data Analysis and Working Sheet

Diagnostic Framework and Differential Diagnosis

Student Name ________________________________________ Date ________________________

I. Clinical Case ________________________________________

Chief Complaint (CC) ________________________________________________________________________

__________________________________________________________________________________________

II. Assessment and Diagnostic Framework scheme (organ and/or anatomical region; mnemonics [VINDICATE])

III. Differential Diagnosis Analysis

Diagnosis

(What diagnosis are you thinking?)

History

(Which data from the History support this diagnosis?)

Physical Examination

(Which data from the Physical Examination support this diagnosis?)

Diagnostic Tests

(What diagnostic tests support, rule out, or confirm differential diagnoses)

IV. Diagnostic Tests (imaging; procedures; lab work tests)

Diagnostic Test

(Which additional test is needed to support diagnosis?)

Indication and Interpretation

(Which finding(s) support the diagnosis?)

V. Clinical Decision Making – Case Study Analysis

___________________________________________________________________________________________________

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Areas of Expertise

Essay

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Dissertation

Term Paper

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Book Review

Assignment

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Coursework

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