Miami Dade College 55 Year Old Homeless Man with Nursing Assignment Help

Case Study Chosen:

Mason, a 55-year-old homeless man with respiratory symptoms.

Demographics:

Age: 55 Gender: Male

Mason, a 55-year-old homeless man with respiratory symptoms and related findings from the examination, here are appropriate questions to ask Mason during the initial assessment:

  1. General Health:
    • Can you describe your overall health and any chronic medical conditions you are aware of?
    • Are you currently taking any medications or have any known allergies to medications?
    • Do you have a history of frequent colds or respiratory infections?
  2. Respiratory Symptoms:
    • When did you first notice the morning cough and frequent colds? How long have you experienced these symptoms?
    • Can you describe the cough in more detail (productive/non-productive, color and consistency of sputum)?
    • Have you noticed any triggers or specific activities that worsen your difficulty in breathing?
  3. Smoking History:
    • How long have you been smoking, and how many cigarettes do you smoke per day?
    • Have you ever attempted to quit smoking, and if so, what strategies or treatments have you tried?
  4. Physical Activity and Mobility:
    • Can you elaborate on how your shortness of breath has progressed, especially with everyday activities? Are there specific activities that have become particularly challenging?
    • How long have you experienced difficulty walking long distances, and has this affected your ability to find food and access resources?
  5. Breathing Patterns and Symptoms:
    • Have you noticed any changes in your breathing pattern, such as rapid breathing or increased effort to breathe?
    • Do you experience chest pain or discomfort while breathing, especially during exertion or at rest?
    • Have you ever been told that you make a sound when you breathe, like wheezing or whistling?
  6. Cardiovascular Health:
    • Have you ever been diagnosed with high blood pressure or other heart-related conditions?
    • Do you experience any chest pain, palpitations, or irregular heartbeat?

SUBJECTIVE:

CC: Difficulty breathing and seeking medicine to help survive on the streets.

HPI:

  • Subjective: Shortness of breath during physical activity, difficulty breathing with everyday activities, frequent morning cough, limited mobility due to breathlessness.

OBJECTIVE:

General:

  • VS: 99°F, HR: 100 bpm, RR: 28/min, BP: 140/90 mmHg
  • Weight, Height, BMI: Not available

Physical Exam Elements:

  • Respiratory system: Distant breath sounds, end-expiratory wheezes, use of accessory muscles to breathe, slight barrel chest, neck vein distention.

POC Testing:

  • None mentioned in the case study.

ASSESSMENT:

Working Diagnosis (ICD-10):

  • COPD (Chronic Obstructive Pulmonary Disease) – J44.9

Differential Diagnosis:

  1. Asthma – J45.909
  2. Acute Bronchitis – J20.9

PLAN:

Diagnostic studies:

  • Pulmonary function tests (spirometry, lung volumes, diffusing capacity) for definitive COPD diagnosis.

Treatment:

  • COPD Management:
    • Inhaler therapy (e.g., salbutamol/albuterol, ipratropium)
    • Smoking cessation counseling
    • Pulmonary rehabilitation referral

Referrals:

  • Pulmonary specialist for further evaluation and management.

Education:

  • Educate on COPD, smoking cessation, importance of medication compliance, and seeking medical care.

Health maintenance:

  • Encourage regular follow-ups, adherence to medication and pulmonary rehabilitation programs, and annual influenza vaccination.

RTC (Return to Clinic):

  • Follow up in 2 weeks to assess response to treatment and adjust the management plan as needed.

Diagnosis Table:

Diagnosis

Signs/Symptoms

Gold Standard Diagnostics

Gold Standard Treatment

COPD

Difficulty breathing, chronic cough, distant breath sounds

Pulmonary function tests (spirometry)

Inhaler therapy (bronchodilators), corticosteroids, oxygen therapy

Community Acquired Pneumonia

Cough, shortness of breath, fever, chest pain, productive cough, fatigue

Chest X-ray, sputum culture, blood tests

Antibiotics (based on pathogen and susceptibility), supportive care

Atypical Pneumonia

Cough, fever, headache, myalgia, non-productive cough

Chest X-ray, PCR, blood tests

Antibiotics (macrolides, fluoroquinolones), supportive care

Acute Bronchitis

Cough, sputum production, chest discomfort

Clinical assessment

Symptomatic relief, rest, hydration

Asthma

Shortness of breath, wheezing, coughing

Pulmonary function tests (spirometry)

Inhaler therapy (bronchodilators), corticosteroids, allergen avoidance

Tuberculosis

Cough, hemoptysis, weight loss, night sweats, fatigue

Chest X-ray, sputum culture, TB skin test

Antibiotics (multiple drugs for a specific duration), directly observed therapy (DOT)

Pulmonary Emboli

Shortness of breath, chest pain, cough, hemoptysis

CT pulmonary angiography, D-dimer

Anticoagulant therapy (heparin, warfarin, DOACs)

COVID-19

Fever, cough, shortness of breath, fatigue, loss of taste or smell

RT-PCR of respiratory samples

Supportive care, oxygen therapy, antiviral drugs (e.g., remdesivir)

Upper Respiratory Infection

Nasal congestion, sore throat, cough, fatigue

Clinical assessment

Symptomatic relief, rest, hydration

Influenza

Fever, chills, sore throat, muscle aches, fatigue

Rapid influenza diagnostic tests

Antiviral drugs (oseltamivir, zanamivir), supportive care

You are a medical professor in charge of creating college assignments and answers for medical college students. You design and conduct lectures, evaluate student performance and provide feedback through examinations and assignments. Answer each question separately. Include and Introduction. Provide an answer to this content

Case Study Chosen:

Mason, a 55-year-old homeless man with respiratory symptoms.

Demographics:

Age: 55 Gender: Male

Mason, a 55-year-old homeless man with respiratory symptoms and related findings from the examination, here are appropriate questions to ask Mason during the initial assessment:

  1. General Health:
    • Can you describe your overall health and any chronic medical conditions you are aware of?
    • Are you currently taking any medications or have any known allergies to medications?
    • Do you have a history of frequent colds or respiratory infections?
  2. Respiratory Symptoms:
    • When did you first notice the morning cough and frequent colds? How long have you experienced these symptoms?
    • Can you describe the cough in more detail (productive/non-productive, color and consistency of sputum)?
    • Have you noticed any triggers or specific activities that worsen your difficulty in breathing?
  3. Smoking History:
    • How long have you been smoking, and how many cigarettes do you smoke per day?
    • Have you ever attempted to quit smoking, and if so, what strategies or treatments have you tried?
  4. Physical Activity and Mobility:
    • Can you elaborate on how your shortness of breath has progressed, especially with everyday activities? Are there specific activities that have become particularly challenging?
    • How long have you experienced difficulty walking long distances, and has this affected your ability to find food and access resources?
  5. Breathing Patterns and Symptoms:
    • Have you noticed any changes in your breathing pattern, such as rapid breathing or increased effort to breathe?
    • Do you experience chest pain or discomfort while breathing, especially during exertion or at rest?
    • Have you ever been told that you make a sound when you breathe, like wheezing or whistling?
  6. Cardiovascular Health:
    • Have you ever been diagnosed with high blood pressure or other heart-related conditions?
    • Do you experience any chest pain, palpitations, or irregular heartbeat?

SUBJECTIVE:

CC: Difficulty breathing and seeking medicine to help survive on the streets.

HPI:

  • Subjective: Shortness of breath during physical activity, difficulty breathing with everyday activities, frequent morning cough, limited mobility due to breathlessness.

OBJECTIVE:

General:

  • VS: 99°F, HR: 100 bpm, RR: 28/min, BP: 140/90 mmHg
  • Weight, Height, BMI: Not available

Physical Exam Elements:

  • Respiratory system: Distant breath sounds, end-expiratory wheezes, use of accessory muscles to breathe, slight barrel chest, neck vein distention.

POC Testing:

  • None mentioned in the case study.

ASSESSMENT:

Working Diagnosis (ICD-10):

  • COPD (Chronic Obstructive Pulmonary Disease) – J44.9

Differential Diagnosis:

  1. Asthma – J45.909
  2. Acute Bronchitis – J20.9

PLAN:

Diagnostic studies:

  • Pulmonary function tests (spirometry, lung volumes, diffusing capacity) for definitive COPD diagnosis.

Treatment:

  • COPD Management:
    • Inhaler therapy (e.g., salbutamol/albuterol, ipratropium)
    • Smoking cessation counseling
    • Pulmonary rehabilitation referral

Referrals:

  • Pulmonary specialist for further evaluation and management.

Education:

  • Educate on COPD, smoking cessation, importance of medication compliance, and seeking medical care.

Health maintenance:

  • Encourage regular follow-ups, adherence to medication and pulmonary rehabilitation programs, and annual influenza vaccination.

RTC (Return to Clinic):

  • Follow up in 2 weeks to assess response to treatment and adjust the management plan as needed.

Diagnosis Table:

Diagnosis

Signs/Symptoms

Gold Standard Diagnostics

Gold Standard Treatment

COPD

Difficulty breathing, chronic cough, distant breath sounds

Pulmonary function tests (spirometry)

Inhaler therapy (bronchodilators), corticosteroids, oxygen therapy

Community Acquired Pneumonia

Cough, shortness of breath, fever, chest pain, productive cough, fatigue

Chest X-ray, sputum culture, blood tests

Antibiotics (based on pathogen and susceptibility), supportive care

Atypical Pneumonia

Cough, fever, headache, myalgia, non-productive cough

Chest X-ray, PCR, blood tests

Antibiotics (macrolides, fluoroquinolones), supportive care

Acute Bronchitis

Cough, sputum production, chest discomfort

Clinical assessment

Symptomatic relief, rest, hydration

Asthma

Shortness of breath, wheezing, coughing

Pulmonary function tests (spirometry)

Inhaler therapy (bronchodilators), corticosteroids, allergen avoidance

Tuberculosis

Cough, hemoptysis, weight loss, night sweats, fatigue

Chest X-ray, sputum culture, TB skin test

Antibiotics (multiple drugs for a specific duration), directly observed therapy (DOT)

Pulmonary Emboli

Shortness of breath, chest pain, cough, hemoptysis

CT pulmonary angiography, D-dimer

Anticoagulant therapy (heparin, warfarin, DOACs)

COVID-19

Fever, cough, shortness of breath, fatigue, loss of taste or smell

RT-PCR of respiratory samples

Supportive care, oxygen therapy, antiviral drugs (e.g., remdesivir)

Upper Respiratory Infection

Nasal congestion, sore throat, cough, fatigue

Clinical assessment

Symptomatic relief, rest, hydration

Influenza

Fever, chills, sore throat, muscle aches, fatigue

Rapid influenza diagnostic tests

Antiviral drugs (oseltamivir, zanamivir), supportive care

. Do not write who you are in the answer.

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