Patient Vivienne Year Question & Answer Guide (With Explanation)

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Original Question

Patient: Vivienne, a 45-year-old female, presents to your office today with complaints of a persistent cough, pleuritic chest pain, and mild shortness of breath over the past 5 days. She describes the cough as productive with yellowish sputum and reports that it has progressively worsened. Vivienne states that she started feeling “off” about a week ago, initially with mild fatigue, a low-grade fever (100.4°F), and a sore throat. Over the past couple of days, she has felt more fatigued, and the cough has become more pronounced, with associated sharp chest pain that worsens with deep breathing or coughing. She also notes feeling mildly short of breath with exertion but denies any wheezing or significant difficulty breathing at rest. Vivienne works as a marketing manager and does not have any known history of chronic lung diseases like asthma or COPD. She is a non-smoker and does not drink alcohol excessively. She has not traveled recently and has no known exposure to anyone with respiratory infections. Allergies: Penicillin (rash) Past Medical History: • Hypertension (well-controlled with lifestyle modifications) • No history of chronic respiratory diseases • No previous surgeries or hospitalizations • Last medical visit was for routine blood pressure monitoring 6 months ago. Immunization History: • Up to date on routine vaccination • Last flu vaccine was administered 3 months ago. • No known history of pneumococcal vaccination. Vital Signs: • Temp: 101.2°F (oral) • HR: 96 bpm • RR: 18 breaths per minute • B/P: 132/84 mmHg • Wt.: 75 kg Physical Exam: • General: Alert, cooperative, appearing mildly fatigued but in no acute distress. • Skin: No rashes, good skin turgor, and normal capillary refill. • Ears: Tympanic membranes dull with no signs of infection or fluid. • Eyes: Sclerae and conjunctiva clear, no redness or discharge. NUR 621 Case Study Pulmonary • Nose: Mild congestion with thin, watery nasal discharge. No significant obstruction or purulent discharge. • Pharynx: Mild erythema of the oropharynx, no exudate or tonsillar enlargement. • Neck: No cervical lymphadenopathy. • Lungs: Diminished breath sounds at the right lower lung base. Crackles (rales) are audible in the right lower lung field. No wheezing. Mild tenderness to palpation over the right anterior chest wall. No signs of pleural effusion (no dullness on percussion). No accessory muscle use or increased work of breathing. • Heart: Regular rate and rhythm, no murmurs, gallops, or rubs. • Abdomen: Soft, non-tender, normal bowel sounds, no hepatosplenomegaly. List five differential diagnoses that you feel are likely to explain this patient’s presentation List your most likely diagnosis first (“working diagnosis”), followed by 4 other reasonable alternatives. Using the grid below each diagnosis, enter the inclusion and exclusion rationale from the history and the physical examination that support each one. Differential Diagnosis Inclusion Rationale Exclusion Rational Working Diagnosis ( ) 1. 2. 3. 4. 5. List the components of your evaluation plan, and provide a rationale for each (why are you prescribing this medication or test? How will it help you make the diagnosis?). Pharmacological Plan (If indicated) Medication and Rationale Recommended mg/kg/day Dose Concentration (if pertinent) Route/ Frequency 1. 2. 3. NUR 621 Case Study Pulmonary Testing: Lab or Radiology Test Rationale 1. 2. 3. Patient Education 1. 2. 3. 4. 5. Follow-Up Plan (May include referrals) 1. 2. 3. 4. 5.

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