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Worsening cough and shortness of breath for Mr. John Barley, a 58-year-old man who has sought medical attention only rarely in the past 10 years

Worsening cough and shortness of breath for Mr. John Barley a 58-year-old man who has sought medical attention only rarely in the past 10 years

While working with your family medicine preceptor you are scheduled to see Mr. John Barley, a 58-year-old man who has sought medical attention only rarely in the past 10 years. He comes to the office today because of progressively worsening cough and shortness of breath during the previous month.

Before you and your preceptor Dr. Wilson enter the room to meet Mr. Barley, you think about the definition of dyspnea:

Dyspnea DeHnition Dyspnea is defined as an uncomfortable awareness of breathing.

Any problem in the mechanical system of breathing can trigger dyspnea, including (but not limited to):

TEACHING POINTTEACHING POINT

7/20/19, 11)31 PMFamily Medicine 28: 58-year-old man with shortness of breath – Sout…ollege of Nursing and Public Health Graduate Online Nursing Program

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blockage in the nose fluid in the alveoli irritation of the diaphragm

Question Dr. Wilson asks you, “What are some of the conditions that lead to dyspnea?”

The suggested answer is shown below.

Pneumonia, CHF, Flu, COPD, Asthma.

Letter Count: 34/1000

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Answer Comment

Causes of Dyspnea It often helps to organize your list of differential diagnoses by system, so that you make sure that it is complete. Also, an organized list can make it easier to rule in or out the diagnostic possibilities.

TEACHING POINTTEACHING POINT

7/20/19, 11)31 PMFamily Medicine 28: 58-year-old man with shortness of breath – Sout…ollege of Nursing and Public Health Graduate Online Nursing Program

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One way to organize the causes of dyspnea in adults is by categories: cardiac, hematologic, pulmonary, or psychogenic:

Worsening cough and shortness of breath for Mr. John Barley, a 58-year-old man who has sought medical attention only rarely in the past 10 years

Cardiac:Cardiac:

Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction

Hematologic:Hematologic:

Anemia

Pulmonary:Pulmonary:

Obstructive lung disease: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis

Diseases of lung parenchyma & pleura: pneumonia, pleural effusion, cancer involving the lungs, pneumothorax, pulmonary edema, restrictive lung disease, interstitial lung disease

Pulmonary vascular disease: pulmonary embolism, pulmonary hypertension

Obstruction of the airway: gastroesophageal reflux disease with aspiration, foreign body aspiration

Environmental irritants and allergens: dust or chemical

Psychogenic:Psychogenic:

Panic attacks, hyperventilation

Other:Other:

Deconditioning Neuromuscular conditions (myasthenia, Gullain-Barre, ALS) Metabolic (carbon monoxide, anion and non-anion gap

acidosis)

Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction, anemia, chronic obstructive pulmonary disease (COPD), asthma,

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pneumonia, pneumothorax, pulmonary embolism, pleural effusion, cancer involving the lungs, pulmonary edema, gastroesophageal reflux disease with aspiration, restrictive lung disease, panic attacks, hyperventilation. Exposure to dust or chemical that causes irritation, an allergic reaction, or poisoning. Deconditioning, because of lack of exercise.

“A couple of things are worth noting here,” Dr. Wilson concludes. “The severity of dyspnea does not necessarily correlate with the gravity of the underlying disease. And we could have chosen “cough” instead of “dyspnea” as the most important symptom to generate a differential diagnosis.” Discussion: Conditions that lead to dyspnea

PATIENT HISTORY 1 HISTORY

Mr. Barley tells you about his current health issues.Mr. Barley tells you about his current health issues.

!

7/20/19, 11)31 PMFamily Medicine 28: 58-year-old man with shortness of breath – Sout…ollege of Nursing and Public Health Graduate Online Nursing Program

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Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.

Also Check Out: Assignment :Factors that support the healing environment

You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you.” Mr. Barley says, “Sure, anyone working with Dr. Wilson is OK by me.”

You begin eliciting the history:

“I understand you have a cough and shortness of breath. Can you tell me more about it?”

“OK. Have you noticed anything else that seems to be related to the cough? Things like weight loss, chest pain, and fever?”

“Have you had any nausea, vomiting, or diarrhea?”

“Do you have shortness of breath when you are active and when you are at rest?”

“Have you had in the past, or currently have, exposures to things that can cause cough, like chemicals, and smoking?”

“Do you have any trouble lying Xat when you sleep?”

You learn that he has not traveled recently, which could have exposed him to an unusual form of pneumonia. He also has not been exposed to tuberculosis. From other questions, you learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). You know that he has had no orthopnea.

As a farmer, he is active during the day. Deconditioning is not likely.

7/20/19, 11)31 PMFamily Medicine 28: 58-year-old man with shortness of breath – Sout…ollege of Nursing and Public Health Graduate Online Nursing Program

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Wondering if his shortness of breath is due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes.

Orthopnea DeHnition Dyspnea which occurs when lying flat, forcing the person to have to sleep propped up in bed or sitting in a chair. It is commonly measured according to the number of pillows needed to prop the patient up to enable breathing (Example: “three pillow orthopnea”).

Paroxysmal nocturnal dyspnea (PND) – DeHnition, Etiology, Symptoms DefinitionDefinition

Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

EtiologyEtiology

It is most closely associated with congestive heart failure.

SymptomsSymptoms

PND commonly occurs several hours after a person with heart failure has fallen asleep. PND is often relieved by sitting upright, but not as quickly as simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.

TEACHING POINTTEACHING POINT

TEACHING POINTTEACHING POINT

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PATIENT HISTORY 2 HISTORY Now that you have a good understanding of the history of the present illness, you continue the interview by turning to past medical, social, and family histories.

You say, “I think I have a clear idea about what brought you in today. Let me ask you now about your health in general.”

“Any serious illnesses in the past?”

“I’d like to ask about your personal life. Tell me about your home life.”

“Tell me about your immediate family health history.”

You say, “So I understand that you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes.”

SUMMARY STATEMENT CLINICAL REASONING After thanking Mr. Barley, you leave the room while he changes into a gown. Seeing you in the hall, Dr. Wilson says, “I can join you now. Can you fill me in on what you have learned so far?”

Question Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.

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Guidelines for summary statements.

Your response is recorded in your student case report.

Letter Count: 0/1000

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Answer Comment Mr. Barley is a 58-year-old male smoker who presents with a two- week history of productive cough and dyspnea on exertion. He has had similar symptoms during the past two winters. He denies fever, chest pain, epigastric pain, symptoms of CHF, recent travel, or TB or chemical exposures.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 58-year-old smoker

2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

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productive cough dyspnea on exertion similar symptoms past two winters no fever, chest pain, epigastric pain, symptoms of CHF, recent

travel, Tb or chemical exposures.

DIFFERENTIAL DIAGNOSIS CLINICAL REASONING

You discuss the differential with Dr. Wilson.You discuss the differential with Dr. Wilson.

!

“Let’s go in and do the physical together,” says Dr. Wilson, “But, first, what are you thinking so far, in terms of a differential?”

After pausing to think, you reply to Dr. Wilson, “He could have bronchitis.”

“Good thought.” Dr. Wilson added, “What in the history supports bronchitis?”

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The best options are indicated below. Your selections are indicated by the shaded boxes.

You reply that the cough and shortness of breath of two to three weeks duration could support acute bronchitis.

Dr. Wilson tells you, “While the duration of illness provides a clinical distinction between acute and chronic bronchitis, the actual mechanisms and pathophysiology also probably differ between the two. Chronic bronchitis causes long-term inflammation that can lead to irreversible structural changes. He might qualify for this diagnosis because he describes cough with phlegm production during the past two winters. But let’s assume for the moment that he doesn’t have chronic bronchitis.”

Discussion: Conditions that lead to dyspnea

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