Assignment task:
Review New Case: Patient Marty is a 72- year-old male.
Chief Complaint: presenting with increasing weakness and tiredness - "just don't feel right".
History of Present Illness: "just not feeling right for the last couple days. Just getting over a cold that he had treated with Mucinex OTC. Now finding he is feeling increasingly tired and weak. State "just didn't want to get out of bed this morning and hasn't been able to take his daily 30 min walk for the last couple days.. Denies headache, fever, rhinorrhea, dysphagia, otalgia, cough, sputum production, chest pain, palpitations. Does admit to feeling congested and some chest tightness with activity. Denies changes in hearing and vision, appetite is good, denies urinary or bowel pattern changes.
Past Medical History: Hypertension x 10 years; Elevated cholesterol & triglycerides x 10 years; osteoarthritis x3 years; Wears hearing aid x6 years and "cheaters for reading".
Family History: Father & Mother deceased - both MIs in their 80s.
Social History: Smokes ½ ppd for 30 years - quit 20 years ago. Drinks 4-6 oz of wine daily. Denies recreational drug use. Retired DEA Agent..
Current Medications: Amlodipine 10 mg daily and Crestor 10 mg daily: Aleve for arthritis prn
Allergies: Penicillin
Vital signs: T: 95.2 P: 84 R: 12 BP: 148/88 O2Sat: 94% Ht: 5'10" Wt: 205 lbs
Pertinent physical exam findings:
HEENT: normocephalic; TMs pearly gray; nares patent with small amount of yellow drainage; pharynx pink, no lymphadenopathy; thyroid nonpalpable;
Cardiac: no JVD; carotids 2+; no bruits; S1 & S2 noted with normal rate & rhythm, no murmurs, clicks, gallops, rubs, 2+ pulses; no edema
Respiratory: Normal AP /transverse diameter; chest expansion symmetrical; no fremitus; mild dullness to percussion in RLL; basilar crackles and expiratory wheezes in R lung; no extra lung sounds.
Abdomen: soft; non-tender; positive bowel sound in all 4 quadrants; no organomegaly noted.
Point of Care Testing Completed (on-site): CBC: WBC: 12.7 Neutrophils: 74% Bands: 12%; Hgb: 14 Hct: 45
Complete the following questions and post to Discussion Board on Blackboard Module 5:
1. What are the patient's most significant key presenting features & risk factors?
2. What are your top three (3) Differential Diagnoses and why? Want Professional Help?
3. What additional diagnostic or imaging testing should be ordered and why?
4. What is the patient's most likely diagnosis?
5. How is the patient's condition typically treated?