Case Study One
Mrs. Jones is a 56-year-old Caucasian female who recently moved to Arizona from Minnesota and is a new patient. She has been feeling tired lately, which she attributes to her allergies. She has been taking Claritin®, but for the past month, it has not been working well. She complains of a runny nose that is worse in the morning, associated with sneezing and an itchy throat. She also complains that her breathing is more difficult. She becomes dyspneic on minimal exertion and can hear herself wheezing throughout the day. She reports using the albuterol inhaler more frequently than every 4 hours. Her productive morning cough seems worse, but the color of her sputum has not changed. She denies discolored nasal drainage, headache, facial pain, loss of appetite, chest pain, edema, and fevers.
Chronic obstructive pulmonary disease (COPD) and seasonal allergies; complaining of recent inability to sleep through the night
Her family history is noncontributory.
Claritin® 10 mg q am and Albuterol MDI 2 puffs q 4 hours prn.
Smoked 2 packs per day for 30 years; quit 2 years ago.
This is a w/d, w/n who is appropriate and cooperative. Vital signs are: Bp 128/72, pulse 88 and regular, respirations 20. She has dark circles under both eyes (allergic shiners), lungs have bilateral basilar wheezing, heart is regular without murmurs, abd is soft, nontender, and BS present.
O2 saturation 92% at room air at rest; spirometry reveals FEV1 = 45%, FEV1/FVC = 65%.© BrainMass Inc. brainmass.com March 22, 2019, 3:19 am ad1c9bdddf
Below is a guideline work up on the given case study in point form to justify the proposed diagnoses for Mrs Jones.
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Diagnoses case study
1.0 Patient History
Mrs Jones is a 56-year-old Caucasian female
1.1. She has been feeling tired lately, which she attributes to her allergies
1.2. She has been taking Claritin®, but for the past month
1.3. She complains of a runny nose that is worse in the morning, associated with sneezing and an itchy throat
1.4. She also complains that her breathing is more difficult.
1.5. She becomes dyspneic(Shortness of breath) on minimal exertion and can hear herself wheezing throughout the day
1.6. She reports using the albuterol inhaler more frequently than every 4 hours.
1.7. Her productive morning cough seems worse, but the color of her sputum has not changed
1.8. She complains of recent inability to sleep through the night
1.9. Smoked 2 packs per day for 30 years; quit 2 years ago.
1.10. She has dark circles under both eyes (allergic shiners)
1.11. lungs have bilateral basilar wheezing
1.12. Spirometry reveals FEV1 = 45%,
1.13. FEV1/FVC = 65%.
2. Suggestive diagnostic criteria
2.1. COPD-Chronic Obstructive Pulmonary disease is a condition which presents as a progressive airflow obstruction, which is not reversible and it does not change over several months. It comprises disorders that include chronic bronchitis (inflammation of bronchial tubes in the lung characterized by cough with phlegm or mucus)and emphysema( a damage of the air sacs(alveoli) of the lung that presents as shortness of breath(National Institute for Clinical Excellence-NICE Guidelines 2004, 2010)
2.2. The main symptoms of COPD include breathlessness, cough and sputum
2.3. The most common cause of both bronchitis and emphysema is long term cigarette smoking and therefore the major cause of COPD is cigarette smoking. Although lung function deteriorates with age in normal individuals, smoking accelerates this damage.
2.4. A key diagnostic method is determination of airflow obstruction in obstructive using spirometry (the use of an instrument called a spirometer for the measurement of the volume of air a patient is able to breathe out or expel from the lungs after taking a deep breath)
Spirometry provides the following useful readings:
2.4.1. Forced Expiratory Volume in 1 ...
This is a guideline that analyses the provided information(i.e patient presenting illness, medical history, family history, social history, medications, physical examination, lab results and determines a diagnosis(es) for the given case study.
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