Instructions Part List Assignment Help: How to Answer This Question
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Original Question
instructions: Part 1: List and define each of the red abbreviations/words in the scenario. Tell what the abbreviations stand for and then describe what they mean. Example – OBGYN – obstetrics and gynecology – an acronym for a physician who specialized in women’s health. Part 2: Use the information gathered to explain to the patient in normal/general (layman’s) terms what the physician understood to be the problem, what was found in the physical exam and tests, the diagnosis, and the plan of care. (These steps represent SOAP therefore, the SOAP labels should be included on each part. Case Study: S: CC: 68 y/o male presents complaining of SOB. HPI: Pt states that he has suffered consistent dyspnea x4 days. States that the issue is worse with exertion and alleviated by leaning forward with arms across his chest. He has noted associated faintness and one episode of syncope yesterday. Syncope was witnessed, pt recovered immediately, no head trauma. PMHx: HTN x12 yrs, CHF x5 yrs, hypercholesterolemia x 7 yrs, MI 2017, NIDDM 2018 PSHx: CABG (x4) 2017 FHx: Lung CA, mother 1996 Meds: Metoprolol (200mg/day), Atorvastatin (40mg/day), Metformin (1000mg/day) Social: Lives at home alone; Smoker (90 pack-years); ETOH 2-3 liquor drinks daily. O: VS: BP: 138/91 T: 36.8 HR: 96 RR: 28 PE: General: Pt is barrel chested and in distress, lips are pursed and he is supporting himself leaning over on the exam table. Chest: hyperresonance on percussion, prolonged expiration, audible expiratory wheezes, no crackles in the base. HEENT: notable JVPs Heart: muffled heart sounds ROS normal unless otherwise noted Radiology: Chest X-ray and CT show hyper-expansion of the lungs consistent with COPD Spirometry: Decreased FEV consistent with emphysema A: 1. Emphysema 2. Smoker, 2ppd 3. CHF 4. HTN P: Tx plan as follows: Albuterol 10mg/hr continuous nebulizer used to treat acute symptoms. Rx for albuterol 5mg nebulized TID PRN, NTE 10mg/day and at-home supplemental oxygen 1-2L/min via nasal cannula given. Smoking cessation information given to patient with education on the importance of quitting smoking with emphysema. Pt to f/u with pulmonology next week for long-term care plan.
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