Problem:
History
A 65 years old former garage mechanic presents with a chief complaint of increased shortness of breath and a change in the quantity and color of his sputum for the past week. The sputum is usually scant and clear. However, recently it has become yellow and continues all day. He has had trouble raising sputum in the past year. He has become progressively short of breath over the last five years. Last year he was diagnosed with COPD. He is now dyspneic and diaphoretic at rest. He denies asthma, childhood respiratory problems, allergies and any occupational exposures.
Physical Examination
Obvious respiratory distress with prominent use of accessory muscles.
Temperature 100.5; Blood pressure 140/90; pulse 110; respiratory rate 28; O2Sat 88%
Chest reveals increased A-P diameter; reduced chest wall excursion; lungs hyper resonant to percussion; diaphragms low and immobile; auscultation reveals a prolonged expiratory phase with diminished breath sounds and generalized rhonchi. There is a significant dullness of breath sounds noted in the RML.
Heart reveals normal heart sounds regular rhythm and no murmurs.
Chest x-ray reveals hyperinflation of lungs with an increase in the retrosternal space; low, flattened diaphragms; hyperlucent lung fields with paucity of vascular markings in the periphery but prominent hila and narrow heart silhouette. Bibasilar infiltrate in RML is noted.
EKG reveals heart rate of 110 bpm, normal sinus rhythm. Impression: Uncomplicated tachycardia. Heart normal size.
Laboratory reveals WBC 12,500 with normal differential and Hgb 12.7 gm.
ABG's:
Ph: 7.37
PaO2: 60
PaCO2: 63
HCO3: 32
Please answer the following questions:
What are your top four (4) differential diagnoses?
Identify your primary diagnosis & explain your rationale - findings that lead you to this diagnosis.
What labs and diagnostic tests would you want to order - give rationale for each.
What is your treatment plan? Identify pharmacologic and non-pharmacological treatments. Be specific with medications & dosages.
What is your plan of follow-up care? Need Assignment Help?
Include information on secondary infections this patient may be susceptible to.