South University Week 2 Chronic Disease Management Discussions Replies

respond to two classmates

classmate 1:

Internal Medicine 08: 55-year-old male with chronic disease management

What is the CC in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you?

CC: “I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control, so I don’t have another heart attack. I am here to get down to work” (Burns, 2021).

In order to create an appropriate HPI it is important to follow the OLDCART pneumonic: onset, location, duration, character, aggravating factors, relieving factors, timing and severity (Goolsby & Grubbs, 2018). Using the OLDCART pneumonic can help assess the patients’ pain, if there is any present, as well as other symptoms the patient is experiencing. Some important questions that should be asked would including inquiring about what medications the patient is currently taking, what kind of food and drinks he typically consumes throughout the day, what his exercise routine consists of and is he able to tolerate such exercise (Bickley & Szilagyi, 2017). It is also important to ask the patient about any visual changes or if they’re experiencing any tingling or numbness in the hands and feet, as well inquiring about their social habits including drug, tobacco, and alcohol use (Bickley & Szilagyi, 2017).

Mr. Morales provided a list of his current medications following his recent heart attack and heart surgery. He provided detailed descriptions of his daily food and beverage intake, which included fast food, soft drinks, hearty meals at home always consisting of meat, gravy, starches and some vegetables, and a large bowl of ice cream in the evening (Burns, 2021). The patient brought a log of his blood sugars he has recorded since leaving the hospital and admits that he will frequently skip his insulin shots because he does not like to give himself shots, and during moments of hypoglycemia instead of taking his blood sugar he skips it and eats a candy bar from the vending machine to avoid the shaky, sweaty, jittery feeling (Burns, 2021). In addition, Mr. Morales informed the provider that he does not have a specific exercise routine other than working on the line and, since his heart surgery, he feels “short of breath just walking to the mailbox at the end of the driveway”, and has also been experiencing numbness in his feet that feel like burning most of the time and his vision is blurry all the time but has not seen an ophthalmologist in some time (Burns, 2021).

What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?

Prior to beginning Mr. Morales’ physical exam vital signs will be obtained, focusing on blood pressure and fasting blood glucose. During the full physical assessment it is important to including his overall general appearance, HEENT, fundoscopic exam, neurologic, neck, cardiac and respiratory, chest appearance, extremities, and diabetic foot exam (Burns, 2021). Positives on the physical exam include a BMI of 39.6 (obese), bilateral microaneurysms with hard exudates on the left, the PMI diffuse and laterally displaced (Burns, 2021). The important negatives to focus on are the absence of S3 S4 heart sounds or edema that could be indicative of the progression of cardiac disease or the onset of recurring heart failure (Burns, 2021).

Which differential diagnosis is to be considered with each case study? What was your final diagnosis?

One of the differential diagnoses to be considered in this case study includes diabetic retinopathy due to his previous diagnosis of diabetes. The patient reported to the provider that he is suffering from constant blurry vision, and upon examination microaneurysms were found bilaterally and hard exudates on the left that were found on the fundoscopic exam (Burns, 2021). Another potential differential diagnosis is diabetic neuropathy due to the persistent numbness Mr. Morales is experiencing in his feet (Buttaro et. al., 2017). The final diagnosis I would give Mr. Morales is heart failure as he is a diabetic who had a recent MI, complains of dyspnea on exertion, and he has cardiac enlargement assessed by a PMI that is diffuse and laterally displaced (Goolsby & Grubbs, 2018).

Internal Medicine 15: 50-year-old male with cough and nasal congestion

What is the CC in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you?

CC: “I have been sick for the past three or four days. It started with my throat being scratchy and lots of sneezing. Now my nose is all stopped up, and I am blowing it constantly. I’m also coughing a lot.”

In order to piece together a detailed HPI it is important to ask the patient about other symptoms he may have experienced such as fever or chills, does he produce any sputum with his cough and if so what color is it, and whether or not he has experienced this symptoms before (Bickely & Szilagyi, 2017). I would also inquire if the patient has ever experienced allergies or if he has taken any OTC medications for his symptoms and if so, which ones and were they helpful (Bickley & Szilagyi, 2017). Additional questions could include are his symptoms triggered or aggravated by anything specific, and in addition to a fever or chills has he felt fatigued or developed a headache (Goolsby & Grubbs, 2018)?

Mr. Talib informed the provider that he felt warm on the first day but now has occasional chills and feels really tired (Bierman, 2021). He also stated that his children were sick all last week but both himself and his children has tested negative for COVID, and has also admitted to usually being a half-pack/day smoker. The patient denies any shortness of breath or chest pain, but stated that his cough has been dry and will wake him up throughout the night several times and experienced the same symptoms last fall that lasted a couple of weeks (Bierman, 2021). As for OTC medications, the patient has tried Actified Cold and Allergy tablets, Cold-EEZE, vitamin C, and Waltussin DM, none of which has provided any relief of symptoms (Bierman, 2021).

What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?

Prior to beginning Mr. Talibs’ physical exam vital signs will be obtained, which were all within normal limits, and a BMI of 28.7. During the full physical assessment it is important to include an assessment of his overall general appearance, HEENT, neck, chest/lungs, and cardiovascular system (Bierman, 2021). Positives on the physical exam included a slightly reddened posterior pharynx with no exudate, tonsillar enlargement, or cobblestoning (Bierman, 2021). Upon auscultation, rhonchi was heard throughout all lung fields, but no wheezes or crackles or dullness to percussion (Bierman, 2021). All other systems reviewed presented with normal findings.

Which differential diagnosis is to be considered with each case study? What was your final diagnosis?

One of the potential differential diagnoses would include allergic rhinitis as the cardinal symptoms include sneezing, watery rhinorrhea, nasal congestion, cough, and postnasal drip. Allergic rhinitis can cause sleep-disordered breathing that can lead to generalized tired feeling but does not cause fever, chills, and other signs of systemic illness (Bierman, 2021). Acute bronchitis is another differential diagnosis for Mr. Talib as it presents with a persistent cough, malaise, chills, and rhonchi present on auscultation. The final diagnosis for this patient is ultimately a viral upper respiratory infection, which is supported by the assessment findings of the slightly reddened posterior pharynx and rhonchi present on auscultation (Goolsby & Grubss, 2018).

Classmate 2 Week 2 Discussion Post

Internal Medicine 08: 55-year-old male with chronic disease management

The chief complaint for case 08 is diabetes and cardiovascular maintenance after a heart attack.

A question that could be asked would be do you smoke? How often do you take your medications? Are there any side effects of the medications you don’t like? This would be asked to see if he has the risk factor of smoking, if he is being compliant with his medications, and if there are side effects that would cause him not to take his medications.

A component of the physical exam that is important is the fingerstick blood glucose. The result of 158 which means his sugars are high if he’s fasting and normal if he isn’t.

Another component is his blood pressure which was 150/90. This means he has stage two hypertension. The issue with this reading is he is already on a couple of antihypertensives. If he is regularly having a reading around 150/90, he either needs to be more compliant with his medications, or he needs to have an increased dose of the medications he is currently on or different ones that will be more effective. (Burns, 2020)

The fundoscopic exam is important on a diabetic patient because diabetes can affect ocular health. The exam showed several microaneurysms bilaterally as well as the left eye having hard exudates. This would support the concern that patient is noncompliant with his diabetic and cardiovascular management and should be referred to an ophthalmologist. (Inzucchi, 2021)

The neck, specifically the carotid pulses, was important to assess due to the patient’s cardiovascular history. The result of a 2+ carotid pulse bilaterally with normal upstroke could mean the patient has a slightly diminished pulse than what a normal pulse should be. (Burns, 2020; Zimetbaum, 2021)

The cardiac system is crucial to assess due to his recent myocardial infarction as well as his diabetes. The PMI being diffuse and laterally displaced could be the result of his recent heart failure and stent placement. (Zimetbaum, 2021)

It is important to do a thorough diabetic foot exam due to his distal symmetric polyneuropathy. He does have onychomycosis, but it is unrelated to the diabetes and cardiovascular conditions. (Burns, 2020; Inzucchi, 2021)

Extremities are very important to exam due to his cardiovascular history. There was no edema, cyanosis, or clubbing which could mean his peripheral cardiovascular system is working appropriately. (Burns, 2020)

The blood work was an important part of the physical exam because of his diabetes having many potential complications that should be monitored. The BUN and creatinine were both high mean as well as the albumin to creatinine ratio.(Burns, 2020; Mottl et al., 2020)

Differential diagnoses would include glomerulonephritis, glomerulosclerosis. (Mottl et al., 2020)

The final diagnosis would be diabetic nephropathy.

Internal Medicine 15: 50-year-old male with cough and nasal congestion

The chief complaint is cough and nasal congestion. Questions that would help would be do you have any allergies? Is this something that has happened in the past or regularly? What color is your nasal discharge?

Because an upper respiratory infection is diagnosed based on signs and symptoms, it is important to do a thorough history and physical exam. Vitals are important to assess to determine if the patient’s infection has impacted his oxygen, respiratory rate, blood pressure, or body temperature. (Sexton & McClain, 2021)

The HEENT is an important part of the physical exam based on his symptoms. His posterior pharynx is slightly reddened. This rules out strep throat due to the absence of exudates. His nasal mucosa also slightly erythematous. This would confirm the patient’s complaint of a runny nose. (Bierman, 2022)

The chest is also important to examine based on his symptoms of cough and congestion. His negative chest exam possibly rules out a respiratory component to his illness such as pneumonia and possible acute bronchitis.(Bierman, 2022)

Allergic rhinitis, acute bronchitis, and acute bacterial pharyngitis are all differential diagnoses. The final diagnosis would be a viral upper respiratory infection based on the symptoms of nasal congestion, rhinitis, cough, malaise, pharyngeal erythema, and sore throat. (Bierman, 2022)(Sexton & McClain, 2021)