Posted: June 22nd, 2022
DQ 15: Current evidence based practice guidelines
DQ 15: Current evidence based practice guidelines
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. She is married and will soon quit her job at the local bakery. She says she has never used tobacco, alcohol, or drugs. Her mother had a stroke and died, and her father had prostate cancer and died of that. She says she hasn’t had a cold or flu recently, and she hasn’t had any other symptoms. From what I can tell, she is not in a lot of pain. Her pulse is 100 and her blood pressure is 160/100. She doesn’t have a fever, and her breathing rate is 16. When you listen to her chest, you can hear air sounds in the distance and late inspiratory crackles in both of her lower lobes. 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.
What is the chief complaint?
Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
What treatment plan would you consider utilizing current evidence based practice guidelines?
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DQ 15: Current evidence based practice guidelines
