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- What is the CC in this case study? What are important questions to ask the patient to formulate the history of present illness and what did the patient tell you?
EB presents with the chief complaint of fever, nausea, vomiting, cough and palpitations. The history of present illness provides a thorough description of the chief complaint and associated problems. It is important to ask questions pertaining to the symptoms that will help in gathering information that will lead to a possible diagnosis. Some essential health history questions to ask EB are:
Why are you seeking help today? I feel bad. I am feeling hot, weak, and sweaty, probably from throwing up.
When did your fever start? I don’t really know. I had the flu last week, felt like I was getting better, but then I just felt worse each subsequent day. Really feeling shaky.
How often do you have fever? I don’t know I just feel hot and sweaty.
Do you have a cough? Yes, it was left over from the flu or cold I had, but now is getting worse
Have you had any contact with other sick people? Yes, lots of kids here at college have been getting sick with the flu
Do you have unusual heart beats (palpitation)? Yeah! I feel this funny skip in my chest. It really scares me. I feel like I am falling apart.
Are you taking any over the counter drug? Yes, a multiple vitamin, calcium tab, and Claritin for spring allergies. Tylenol for the flu last week.
Do you have problem with nervousness, depression, lack of interest, sadness, memory loss or mood changes or ever hear voices that you know are not there? I just get anxious but I think that just because I feel so sick.
Have you gained or lost weight unintentionally and despite normal appetite and exercise? I’ve been and losing weight. I eat like crazy except these last 24 hours, but I keep losing weight. I probably need to eat better. Probably should use protein shakes. I do seem to be eating all the time.
Do you feel anxious? Yeah and it is not like me. I am usually happy, easygoing. Now I am just a bundle of nerves, anxious about everything.
- What components of the physical exam are important to review in this case? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?
It is important to do a complete physical examination so that diagnosis is not missed. The component of the physical exam that are significant to this case are cardiovascular system, respiratory endocrine, gastrointestinal and the psychological sate. The presence or absence of critical signs and symptoms will aid the assessment and the severity of the presenting complaint that could potential be life-threatening (Goolsby, & Grubbs, 2011). The things that are important in the assessment of this patient are tachycardia, palpitations, new flow murmur, oligomenorrhea, changes in bowel movements, enlarged thyroid with thrill and bruit, insomnia and exercise intolerance. Pertinent information that are also important are findings from the labs and diagnosis testing. The findings are the WBC 14,360, blood cultures are positive for S. pneumoniae, negative urinalysis and negative toxicology testing. Other findings are elevated blood pressure (160/68) and elevated heart rate (150)
·Which differential diagnosis is to be considered with this case study? What was your final diagnosis?
Hyperthyroidism occurs when there is an over production of the hormone that is made by the thyroid glands. According to the US National Library of Medicine (2017), hyperthyroidism can affect an individual’s metabolism, cause nervousness, increased sweating, tachycardia, hand tremors, problems sleeping, increased appetite; weight loss; changes in menstrual patterns (usually lighter flow, less frequent periods) in women; Increased sensitivity to heat; changes in bowel patterns; and an enlarged thyroid gland (called a goiter), which can appear as a swelling at the base of the neck. Hyperthyroidism is chosen as the diagnosis as the patient (EB), is showing the classic symptoms of hyperthyroidism. Some of the symptoms that the patient has are tachycardia 150 beats per minute; nervousness; agitation; feeling hot, weak, and sweaty; and flu like symptoms. The patient also has an elevated T4 and T3, and a decreased TSH.
Sepsis is caused when bacteria enters the blood stream. Some common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. Sepsis was chosen as a diagnosis as the patient has a positive blood cultures for S. pneumonia. The patient also had the common symptoms of sepsis, and had more than four sirs alert.
Pneumonia was chosen as a differential diagnosis based on the symptoms the patient was experiencing. The patient has fevers, nausea, vomiting, and a productive cough, Pneumonia was ruled out as the patient had a negative chest x-ray.
Intoxication was chosen as a differential diagnosis based on the symptoms the patient was experiencing. The patient skin is sweaty, has tachycardia, fevers, and heat intolerance. Intoxication was ruled out as the patient states that she drinks alcoholic beverages occasionally, and any use of street or recreational drugs.
Goolsby, M.J, & Grubbs, L. (2011). Advanced assessment: Interpreting findings and Formulating a Differential Diagnoses. (2nd ed.). Philadelphia, PA: Davis.
US National Library of Medicine. (2017). Hyperthyroidism. Retrieved from https://medlineplus.gov/hyperthyroidism.html