How you arrived at this diagnosis, or differentials, Why you arrived at this diagnosis, Supporting signs and symptoms, Discordant signs and symptoms, Abnormal signs and symptoms that fit with the diagnosis and differentials, What more do you need to know and How will you find these issues out. Defend your plan of treatment based on evidence based care and use references to EBP guidelines
john is a 66-year-old male who presented to the ed with complaints of increasing shortness of breath. you are the admitting hospitalist. the history of his present illness included an ‘‘asthma-like’’ reaction to environmental triggers, such as odors and chemicals, subsequent to anhydrous ammonia exposure 20 years ago. he had been using ‘‘puffers’’ for this problem with improvement of symptoms and good exercise tolerance. medications included: furosemide, losartan, metformin, acetylsalicyclic acid, budesonide, salbutamol, and nitrodur patch.
past medical history included an inferior wall myocardial infarction (mi) 3 months ago. his echocardiography results from 3 months before showed regional inferior and posterior wall hypokinesis, mild left ventricular systolic and diastolic dysfunction, and a mildly calci?ed aorta. his history included hypertension, type (2) diabetes mellitus, increased cholesterol, and asthma. he is obese and had been diagnosed with sleep apnea in the past.
john admitted to consuming ‘‘a few’’ alcoholic beverages per day and considerably more when he goes to week-end dances. currently he is a smoker, 40 packs/year.
john is a retired widower who lives alone in a rural community.
vitals: john had a heart rate of 136 with a blood pressure of 91/63. blood sugar was 486 with + ketones in blood and an anion gap of 26. abg was 7.17, co2 26, po2 65, bicarbonate 10
respiratory: his respiratory rate was 32 breaths per minute. on oxygen (o2) at 2 l/min per nasal prongs, his o2 saturation was 95%. decreased air entry to bases bilaterally and dullness to percussion from the fourth thoracic vertebrae to the base in the left lung, reduced tactile fremitus ,a pleural friction rub, and asymmetric expansion of the thoracic
neuro: he was alert and oriented and able to speak in complete sentences.
cardiac assessment revealed a grade ii/vi systolic ejection murmur heard at the apex. he denied chest pain at this time. pitting edema was present to the knee level bilaterally. jvp was dif?cult to assess but appeared to be elevated.
initial lab work including a complete blood count with differential, cardiac enzymes, renal panel, and liver function tests, as well as a urinalysis was unremarkable. electrocardiogram (eeg) was read as sinus tachycardia with non-speci?c st wave depression and met criteria for left ventricular hypertrophy. cxr and computerized tomography (ct) scan were performed on admission and were consistent with a large left-sided pleural effusion with some loculation.
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1. 1. develop a problem list
2. per light’s criteria develop a list of possible etiologies of john’s pleural effusion : for example there are four, these are your differentials until the lab results from the thoracentesis is known. treatment is very different for each. provide a brief description of each differential
thorocentesis was performed:
approximately 2 l of clear yellow pleural ?uid was drained and analyzed for protein, ldh, gram stain, acid fast bacilli (afb) and tb culture, cytology, and microbiological culture. macroscopic and cytological examination of the pleural fluid: small cell count that consisted of a mixture of macrophages and mesothelial cells. there was no evidence of polymorphic leukocytosis. there was no predominance of lymphocytes, there was no evidence of tumor cells present in the pleural ?uid.
microbiology examination of the pleural ?uid was negative for afb. gram stain and culture of the pleural ?uid were also negative.
protein-pleural protein to serum protein level- <0.5
3. what type of pleural effusion is this, and why did john develop it?
whwhat are your treatment options?
grading criteria nu 580
promptness and initiative
did not address the key points in the directions or posted after the due date without permission
thoughtful response with general references, and some evidence-based practice. apparent that the student read and completed the assignments but had some errors related to the key concepts
answered all required information and submitted on-time following all directions related to the dq
mechanics of writing
poor spelling and grammar in posts
some errors in spelling and grammar but overall format was clear
submissions were grammatically correct with rare misspellings, easy to read, professional delivery
critical thinking, clinical reasoning & analysis
remarks to dq were opinion based and not backed up by science or other sources, did not read the assignment or spent minimal time looking up and answering the discussion. missed significant explanation related to the physical assessment, diagnosis, chief complaint, pathophysiology etc. points 2.5
answered most of the key points in the directions.
missed some explanation related to the physical assessment, diagnosis, chief complaint, pathophysiology etc.
thoughtful, comprehensive responses with specific references to concepts in the assignment or outside the assignment. responses were thought provoking and creative and stimulated new knowledge on how diagnosis and differentials were generated.
responses to peers were minimal and did not address the directions given for an adequate response
the response to peers only agreed to their treatment plan and did not address alternative testing, treatment options or newer potential options for treatment or testing
response to peers were thoughtful and added to the conversation; made a valid argument on alternate testing and treatment options, may have provided additional newer based procedures or drug therapy
Structure: soap note form using vindicate for differential dx