Question - After reviewing the information below, what additional information would be necessary, if any, to make a diagnosis? At this point, what is your differential diagnosis?
CHIEF COMPLAINTS
Mr. Smith, an 80 y/o, 90kg, African American male, arrives at the Emergency Department, having been driven in by his wife, complaining of "difficulty breathing". Upon arrival, he is placed in an examination room and immediately assessed. The following results have been recorded;
SpO2....................91% on RA
HR........................98
Temp.....................98.0 F
RR.........................28
The patient states that he feels short of breath and has been feeling so off and on for the past two days. His SOB is not related to exertion but does become more SOB with minimal effort. The medical staff in charge of his care noticed that Mr. Smith is unable to speak in full sentences. BS reveal diminished breath sounds. Ten minutes later other vitals are taken, and the following is reported;
CBC
RBC.....................5.8 x 10^6/mm^3
WBC.....................7.6 X 10^3
HCT.......................37.7%
Hb..........................10 g/dL
platelets................262 X10^3
BG........................325 mg/dl
BUN....................43 mg/dl
Creatinine.......3.7 mg/dl
HbA1c...........8.1%
Patient denies any chest pain but does state he's had indigestion for the past 24 hours without relief from two doses of Bismuth Subsalicylate and a general feeling of malaise. Pt denies any smoking. However, he admits to enjoying a cigar from time-to-time for the past 40 years. Mr. Smith considers himself a non-smoker because he does not inhale when enjoying his cigars.
Attachment:- Assignment.rar