Week 4 : Shortness of Breath Discussion Essay

Week 4 : Shortness of Breath Discussion Essay

Week 4 : Shortness of Breath Discussion Essay

Week 4 Discussion: Shortness of Breath

Over the last month, the sixty-year-old lady presented to the facility with a nonproductive cough and increasing shortness of breath. The symptoms were generalized and persistent, aggravated by physical activity and relieved by sleeping upright in a recliner at night. The severity of the symptoms was significant to how it affected her activity level. She has a history of hypertension, coronary artery disease, and a hysterectomy. On examination, she has no acute distress, distant air sounds, and late inspiratory crackles. Therefore, the patient’s chief complaint is shortness of breath and a nonproductive cough over the last month.

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Differential Diagnosis

The differential diagnoses established from the subjective and objective data presented include Congestive Heart Failure (CHF), pulmonary fibrosis, and Chronic Obstructive pulmonary disease (COPD). The patient had a one-month history of worsening breathlessness and a dry cough, symptoms that could be consistent with congestive heart failure, which is a failure of the circulatory system to satisfy body demands (Malik et al., 2022). The presence of distant air sounds, late inspiratory crackles in both lower lobes, increased blood pressure, tachycardia, and an S3 sound over the apex beat may also support this diagnosis.

The patient’s one-month history of worsening breathlessness and an ineffective cough could be consistent with COPD. The bakery presents an occupational danger because COPD is linked to structural lung alterations brought on by chronic inflammation following repeated exposure to toxic substances (Agarwal et al., 2022). On auscultation, far-off air sounds and the late inspiratory crackles from both lower lobes may also support this diagnosis. The patient does not smoke, though. Patients typically complain of persistent dyspnea, a cough, and the generation of sputum (the baker’s cough was unproductive).

The hallmark signs of idiopathic pulmonary fibrosis are nonproductive coughing and increasing dyspnea. Dyspnea with exercise and cough are the most typical IPF symptoms, followed by weariness (Krishna et al., 2020). During inspiration, the traditional pulmonary exam typically detects bibasilar crackles. The majority of the findings agree with the baker’s case.

Confirmatory Diagnosis

The extent of the symptoms and the physical examination results are considered to diagnose and categorize heart failure. We can use The Framingham Diagnostic Criteria for Heart Failure. The condition can be diagnosed if at least two major requirements are met or one major criterion and two minor ones are. The patient has a third heart sound which is in the major criteria, and dyspnea on exertion and cough which are minor criteria. Blood tests for biomarkers, such as brain natriuretic peptide, and imaging techniques like electrocardiogram (ECG), echocardiography, and chest X-ray, may all be used as diagnostic tools. The severity of the ailment and the patient’s requirements will determine the CHF treatment plan.

Evidence-based treatment Approach

The most recent evidence-based practice guidelines suggest a mix of medicines, lifestyle modifications, and routine monitoring to manage CHF (Heidenreich et al., 2022). Diuretics to minimize fluid retention in the body and lungs, Angiotensin Converting Enzyme inhibitors or angiotensin II receptor blockers to improve heart function and alleviate symptoms, and beta-blockers to lessen the strain on the heart can all be used as medications. Lifestyle changes may involve reducing salt intake, increasing exercise, and avoiding coffee. Frequent monitoring is necessary to handle potential issues and alter the treatment approach. Hospitalization may be required in severe CHF instances to control symptoms and improve the patient’s health.

References

Agarwal, A. K., Raja, A., & Brown, B. D. (2022, August 8). Chronic obstructive pulmonary disease (COPD). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559281/

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., & Milano, C. A. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American heart association joint committee on Clinical Practice guidelines. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063

Krishna, R., Chapman, K., & Saad Ullah. (2020, August 16). Idiopathic pulmonary fibrosis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448162/

Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022, September 19). Congestive heart failure. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/

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Discussion
This week’s content addressed common chronic diseases. Please review the case study below and answer the following questions:
A sixty-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can’t do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke, and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination, she is in no acute distress. Her blood pressure is 160/100, and her pulse is 100. She is afebrile, and her respiratory rate is 16. With auscultation, she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination, the S1 and S2 are distant and an S3 is heard over the apex.
1. What is the chief complaint?
2. Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
3. What treatment plan would you consider utilizing current evidence based practice guidelines?

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Definition of differential, presumptive and confirmatory diagnosis
Daphnie Bharadwa posted Apr 11, 2023 2:49 PM
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Dear Class
• Differential diagnosis: The process of weighing the probability of one disease versus that of other diseases possibly accounting for a patient’s illness. The differential diagnosis of rhinitis (a runny nose) includes allergic rhinitis (hayfever), the abuse of nasal decongestants and, of course, the common cold.
• Presumptive diagnosis: identifies the likely condition of a patient.
• Confirmatory diagnosis: labs/imaging/+ Physical exam findings is/are needed to confirm the condition.
• Example: A patient reports having a sore throat accompanied by a fever and a dry cough since yesterday. He stated that drinking cold liquids provides mild temporary relief of the sore throat, he also stated that talking, eating and drinking hot liquids, make the sore throat feel worse. He is using salt water gargles and tylenol to treat his symptoms. Denies feeling nasal congestion, or having a runny nose, sinus pressure or heartburn (noticed how I used the OLDCART here??).
• Differential diagnoses: Allergic rhinitis, Acute viral pharingitis, GERD, Mononucleosis, Acute upper respiratory infection
• Presumptive diagnosis: Sore throat (waiting for lab/imaging test results to make a definitive diagnosis). My diagnosis is related to his main symptom.
• Confirmatory diagnosis: Streptoccocal pharingitis (this was confirmed by a positive rapid Strep test). Do NOT ever make a hypothetical diagnosis… you must always have a confirmatory test or physical exam finding to support a diagnosis.
Make it a habit to include at LEAST 3 differential diagnoses and try your best to make one of those diagnosis a “malignancy”, that will make you do the necessary testing to rule out the worst possible diagnosis. Read the case I posted about the young patient who was diagnosed with a devastating condition( https://urldefense.proofpoint.com/v2/url?u=https-3A__www.clinicaladvisor.com_most-2Dmemorable-2Dpatient_neck-2Dand-2Dchest-2Dpain-2Din-2Da-2Dstudent_article_743138_&d=DwIFAg&c=VJcX3xJwJKggcmYZP-xVNfKwBnVBQf3uSOPll1vxQbo&r=Qercz9eOro7xclzkVw312iZ1Lq8PyruK_ba1bfBRbrg&m=cu3MQ3W11SU3Fa_JUV2uKhoVi1vNxP0qeARe1eo7YnY&s=YC6VGcotudAMtOsWurHIPmWwMA5zl7aq8dtBJJwuE3c&e= )…
I had a patient several years ago who presented just like that… She was very young, smoker since middle school, she kept coming in with a dry cough, doctors kept refilling her cough medicine. This time it was my turn to see her for the refill. I checked her chart and noticed she’s been with the cough for almost 6 months, so I ordered a STAT x-ray. She went to have it done right away because I said I would not write the refill until I saw the x-ray result. A few hours later I got a phone call from a very concerned radiologist, he asked me to fax a Rx for a MRI with and without contrast, he saw a mass in the x-ray and needed more advanced images to know exactly what it was. Less than an hour later, my patient was diagnosed with a Thymoma! 6 months of symptoms and NOT ONE SINGLE PROVIDER BOTHERED to investigate. Needles to say, her cancer was metastasized by the time we found it. She received Chemo to buy her some time, but unfortunately she passed away a few months later.