Assignment Details: Case Study 2, November 12, 2016, 2:00 PM

Assignment Detailscase Study 2date November 12 2016 200 Pmlocatio

Provide a concise, focused report describing the patient's current condition related to the acute problem, including relevant history, physical exam findings, and initial differential diagnoses. Do not include extraneous details not directly impacting management decisions.

Paper For Above instruction

Today, I am presenting Amanda Smith, a 69-year-old Black female with a five-day history of persistent cough that has recently become daily and productive, with frothy sputum. Her cough is disturbing her sleep, and she now reports shortness of breath. Her vital signs show a temperature of 101.4°F, respirations at 30 with labored breathing, and an oxygen saturation of 90%. She exhibits mild respiratory distress with tripod positioning. Physical exam reveals dry skin, dehydration signs such as skin tenting, and bilateral lower extremity edema up to the ankles that improves with elevation. Lung auscultation is notable for no crackles or abnormal sounds, though she demonstrates increased work of breathing. Cardiac examination shows a regular rhythm at 110 bpm, and no murmurs are present. She has a history of hypertension managed with hydrochlorothiazide, and her clinical picture suggests congestive heart failure, possibly precipitated by her recent respiratory infection.

Her history includes a dry cough initially non-productive, now productive with frothy sputum, worsening over the past two days, with associated dyspnea that interferes with sleep. She also has decreased appetite, dry skin, and bilateral pedal edema. She was vaccinated appropriately for pneumococcus and influenza. No recent chest pain, fever of 101.4°F, or other systemic complaints. Her medical history of hypertension and current signs of volume overload point toward congestive heart failure as a leading diagnosis, potentially triggered or worsened by an infectious process such as pneumonia or influenza. Differential diagnoses include community-acquired pneumonia, acute bronchitis, influenza, and exacerbation of heart failure.

In summary, the patient presents with signs suggestive of decompensated congestive heart failure, characterized by edema, dyspnea, cough with frothy sputum, and labored respirations. Immediate management should focus on stabilization, oxygen therapy, and further diagnostic work-up to confirm the diagnosis and initiate appropriate treatment.

References

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