Case Summary:
Case Setting: This is a focused visit in a primary care setting.
Case: Jamie Mackey is a 65-year-old Caucasian male with chief complaint of progressive increased in shortness of breath, recently. Patient's actual diagnosis is heart failure.
Case Setting: A 65-year-old male presents to clinic to see the nurse practitioner for increased breathlessness. Patient states, "I'm having difficulty breathing." This is a focused visit in a primary care setting.
Objective Data (not in the Video)
Physical findings and vital signs:
Vital Signs: BP: 150/100, OT: 98.4 orally HR: 90 & regular RR: 22 Ht: 5 ft, 11 inches, Wt: 220
General: Well developed, overweight male, appears stated age; no acute distress
Respiratory: Chest - dullness and decreased breath sounds at the right base; bibasilar rales.
Cardiovascular/peripheral vascular: JVD to the angle of the jaw in the sitting position. LV impulse diffuse, laterally displaced. Parasternal lift present. S2 physiologically split, S3 at apex, grade II/VI pansystolic murmur at apex; 2+ pedal edema bilaterally.
Gastrointestinal: Abdomen - liver enlarged. Patient has discomfort in upper right abdomen.
Skin: warm, dry to touch; color pink
Answer the following questions:
Question 1: What are the pertinent positives and negatives learned from the HPI and review of systems (ROS)?
Question 2: Based on the subjective findings of the chief complaint and HPI, what are the top three differential diagnoses? Support your choices with rationales.
Question 3: Is/are there any medication(s), over the counter drugs, vitamins or herbs that can potentially be causing this patient's symptoms?
Question 4: In conducting a physical examination in a patient with suspected heart failure, what are the physical findings that may present in a patient with heart failure?
Question 5: Identify pertinent positives and negative in the physical findings. Explain the meaning of these findings. How do they assist in the ruling in or out a differential diagnosis?
Question 6: What diagnostic test are the most appropriate to order during this visitation? Explain your rationale or ordering each test(s). Want Assignment Help?
Question 7: Based on the differentials and plan of care what are some preventative care measures or health promotion initiatives that could be included?