Case Study For Patient With Fatigue And Difficulty To Breath
Case Study For Patient With Fatigue And Difficulty To Breath
Case Study 1
This paper seeks to examine the case of a 58-year-old female who primarily complains of excessive exhaustion as well as having trouble breathing normally. She is employed at the community procurement department on a biweekly basis in the role of a sales associate. She also gives her time as a volunteer at the community library, where she works only once a week. However, she is taking a break from her duties due to exhaustion at the moment. Hypertension is a health condition that runs in her family. Both of her parents were known to have a stroke while they were in their later years. The patient acknowledges that she smoked in the past and states that she has a 40-pack-a-year history, but she was able to kick the habit successfully. In her past medical history, it is noted that she did not test positive for asthma or any other respiratory disorders. However, she has a history of hypertension, type 2 diabetes, and elevated cholesterol. She has been operated on in the past and has had procedures such as appendectomy, cataract removal, and hysterectomy Case Study For Patient With Fatigue And Difficulty To Breath.
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Congestive heart failure, chronic obstructive pulmonary disease (COPD), and pneumonia are the three illnesses that should be taken into consideration in differential diagnosis for this patient. The patient’s symptoms of exhaustion and difficulty breathing point toward the diagnosis of congestive heart failure as one of the probable possibilities. These two symptoms are the most prominent signs of congestive heart failure (Polikandrioti et al., 2019)Case Study For Patient With Fatigue And Difficulty To Breath. The patient also has a history of type 2 diabetes, elevated lipids, and hypertension, all of which are risk factors for congestive heart failure. When taking into account the patient’s smoking history, COPD is another diagnosis that may be considered. The fact that her cough and difficulty breathing have healed in the past after receiving therapy, on the other hand, renders this condition less probable. Given the patient’s history of cough and difficulty breathing, pneumonia is the third likely diagnosis. The presence of crackles in the patient’s lungs during auscultation may have been the result of excessive secretions in the airways, which is a symptom that is often associated with pneumonia (Arts et al., 2020)Case Study For Patient With Fatigue And Difficulty To Breath. As such, I would consider pneumonia the final diagnosis.
In ruling out congestive heart failure, it would be necessary to do a thorough examination of the heart muscle, which would include determining the strength of the pumping activity of the heart as well as the thickness of its walls. To rule out COPD, a pulmonary function test would be crucial in measuring lung function and capacity (Rawat & Sharma, 2021)Case Study For Patient With Fatigue And Difficulty To Breath.
Laboratory tests, such as those on blood and mucus, would be necessary to run as part of a further examination in this case. Such testing will assist in identifying any potential infections and pathogens that are underlying the patient’s condition. An X-ray of the chest is also necessary to determine the degree and indications of infection. In addition, pulse oximetry has to be reevaluated in order to establish how the lungs facilitate the transport of oxygen throughout the circulation.
Considering the determination of pneumonia as the final diagnosis, this patient’s treatment plan would involve prescribing an antibiotic like amoxicillin and educating her to understand her current condition and possible solutions to improve it. She should be advised to take rest and a lot of fluids to avoid dehydration.
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Conclusively, a proper diagnosis may both enhance the efficiency of treatment and help patients avoid developing any long-term complications as a result of their conditions. When patients receive correct diagnoses, they have the highest chance of favorable health outcomes. This is due to the fact that clinical decision-making will be adapted to a proper comprehension of the health situation that the patient is experiencing Case Study For Patient With Fatigue And Difficulty To Breath.
References
Arts, L., Lim, E. H., Van de Ven, P. M., Heunks, L., & Tuinman, P. R. (2020). The diagnostic accuracy of lung auscultation in adult patients with acute pulmonary pathologies: A meta-analysis. Scientific Reports, 10(1). https://doi.org/10.1038/s41598-020-64405-6
Polikandrioti, M., Kalafatakis, F., Koutelekos, I., & Kokoularis, D. (2019). Fatigue in heart failure outpatients: Levels, associated factors, and the impact on quality of life. Archives of Medical Science – Atherosclerotic Diseases, 4(1), 103-112. https://doi.org/10.5114/amsad.2019.85406
Rawat, D., & Sharma, S. (2021). Case study: 60-year-old female presenting with shortness of breath. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499852/Case Study For Patient With Fatigue And Difficulty To Breath
NSG 6420
CASE STUDY 1
Chief Complaint
A 58 year old female presents with fatigue and difficulty catching her breath. Although she has frequently coughed for months, the fatigue and shortness of breath have increased over the past 2 months. She has been treated twice in the past year for bronchitis, which included a severe cough with yellow sputum, shortness of breath, and fever. Once treated, the shortness of breath resolved until recently. She is a former smoker, describing a 40-pack-a year history and finally quitting successfully on her 58th birthday.
Past Medical History
- Negative for asthma and other respiratory conditions
- Type 2 diabetes, hypertension, and increased lipids
- Surgeries: hysterectomy at age 55; an appendectomy in her teens; cataract removals earlier this year Case Study For Patient With Fatigue And Difficulty To Breath
Current Meds
- Atorvastatin 10 mg daily
- HCTZ 25 mg daily
- Metformin 500 mg bid
- Atenolol 25 mg daily
Family History
- Both parents, hypertension
- Father, stroke at age 75
- Mother, diabetes most of life, stroke at age 80, breast cancer
- Sister, hypertension, breast cancer
Psychosocial History
Works 2 days a week as a sales associate in the local department store and volunteers 1 day a week at the local library. Has recently taken a leave from her volunteer role and has decreased from 8 hour to 4 hour work days at the store because of the fatigue. Used to walk daily but has quit this lately, as she says, “It is all I can do to make the bed some days”.
Physical Examination
- Vital signs: T 98, BP 138/86, HR 92, RR 33, HT 64, WT 155 lbs.
- General: Appearance in no acute distress. Alert and oriented. Well groomed. Articulate and seems to be a good historian. Fluid movements.
- CV: S1/S2 without audible extra sounds or murmurs.
- Lungs: Initially some crackles, which cleared with forceful cough. Decreased breath sounds, slight wheeze noted. Slight increased AP ratio.
- MS: Full ROM, non-pitting edema ankles/feet bilaterally. Pulses 2+ bilaterally. Case Study For Patient With Fatigue And Difficulty To Breath
Questions
- What three conditions would be considered in your differential diagnosis, with most likely condition listed first (provide rationale)?
- What further history, further reexamination, and diagnostic studies are warranted to evaluate your differential diagnosis?
- What further evaluation or work up should be done for this patient?
- What is the final diagnosis? Case Study For Patient With Fatigue And Difficulty To Breath
| All Questions in Case Study Answered Correctly | 10 | |
| Introduction & Background: Give the reader a description/scenario of the patient in the case study. Since this is worth 15 points please make sure you have at least 3-4 well-structured paragraphs. | 15 | |
| Pathophysiology: Discuss the pathophysiology related to your final diagnosis for this patient. Since this is worth 15 points please make sure you have at least 3-4 well-structured paragraphs. | 15 | |
| Diagnostics & Labs: Identify all possible lab and other diagnostic tests which could be potentially ordered in the care of patient. | 10 | |
Treatment Plan: discuss appropriate treatments (pharmacologic and non-pharmacologic) regimens and interventions
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15 | |
| Conclusion & Articles: Identify a minimum of two peer-reviewed evidence based article that support your treatment/care plan. Summarize your case and treatment plan in a 1-2 paragraph conclusion/summary | 15 | |
| APA format: title page & reference page.
Please review APA 7th edition for what is expected in an APA 7th ed. paper. Proper use of grammar and clarity of writing style to include spell check. |
10 | |
| References: Cites in AP format throughout paper to include a minimum of three peer-reviewed evidence based practice nursing journals. | 10 | |
| Total: | 100 |
Case Study & Care Plan Grade Rubric