Discussion #1

· What is the CC in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you?

The CC in the first case study with Mr. Morales is diabetes management post heart attack and open-heart surgery a month ago. The important questions to ask is to find more information regarding current diabetes management and compliance to management. Open ended question allows practitioner to draw information from the patient (Dunphy, Winland-Brown, Porter, & Thomas, 2019). Starting with the question tell me more allows patient to elaborate more. Questions regarding blood glucose monitoring, medications, and compliance with medications would give insight of current diabetes management. Patient was saying his job as the reason for not being able to see provider at clinic and also not being able to check his blood sugar. Cost of testing strips. Patient has been checking his blood sugar since his heart attack, but worried he won’t be able to once the testing strip runs out. Mr. Morales also provides list of medications currently taken. Blood glucose readings are above 200 on days he didn’t take his insulin shot.

The CC in the second case study with Mr. Kaleb is rhinorrhea for 3-4 days. The use of mnemonics “OLDCARTS”, practitioner can get more information from the patients of present illness. The seven attributes of a symptom are critical to help understand presented illness which are Onset, Location, Duration, Character, Aggravating/alleviating Factors, Radiation, and Timing (Bickley & Szilagyi, 2017). The mnemonics “OLDCARTS” help provider ask the proper question to elaborate present illness. I would ask if there if there is anything that makes the symptom better or worse? If there are any other symptoms like shortness of breath and associated with current symptoms. Patient answered questions with medications that he tried for symptom relieves although non-effective. Mr. Kaleb have no shortness of breath and “feeling warm the first day but now I just have the chills occasionally.”

· What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?

The physical exams that are important to review in Mr. Morales case are his vital signs and cardiac based on his recent heart attack. Extremities, neurologic, fundoscopic, and foot exam are important to assess in patient with diabetes. Patient continue with high blood pressure reading 150/90 indicates need for hypertension management. Positive findings of microaneurysm on bilateral eyes, hard exudates on the left are signs of diabetic retinopathy. Diabetic foot exam finds decreased sensation to monofilament and vibration to the mid-shin, onychomycosis, and +1 dorsal pedis and posterior tibialis pulses bilaterally. Exam was negative for foot ulcers. Findings suggest patient have neuropathy to his lower extremities.

In Mr. Kaleb case, the EENT and respiratory systems are important to review in this case. The positive findings of rhinitis and cough is important as well as the negative findings of itchy, watery eyes, fever, purulent sputum, sinus and maxillary tenderness, and no exudates or tonsillar enlargement to rule out differential diagnosis.

· Which differential diagnosis is to be considered with each case study? What was your final diagnosis?

The first case scenario with Mr. Morales there are multiple chronic disease presented which are hyperlipidemia, hypertension, type 2 diabetes, obesity, coronary artery disease with history of heart attack. Patient’s main concern during this visit is his type 2 diabetes making it the primary diagnosis. The diagnoses of obesity, hypertension, hyperlipidemia, and type 2 diabetes frequently occur together (Dunphy, Winland-Brown, Porter, & Thomas, 2019). The lifestyle changes these chronic diseases are the same, therefore it would help improve all others chronic diseases.

In Mr. Kaleb’ s allergic rhinitis, acute bronchitis, and viral upper respiratory infection are the differential diagnosis. Allergic rhinitis is unlikely since patient lack the symptoms of sneezing, rhinorrhea, nasal obstruction, and nasal itching (DeShazo & Kemp, 2019). With the early onset of disease, non-productive cough, and afebrile, acute bronchitis is not suspected. Viral upper respiratory infection is the final diagnosis for Mr. Kaleb based on his symptoms and examination.

Discussion #2

What is the CC in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you? Mr. Morales presented with a CC of “I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don’t have another heart attack. I am here to get down to work.”  Important questions to ask the patient include dietary history, personal willingness to adhere to treatments, current medications, and medication compliance.

The patient reported that his diet was noncompliant with cardiac and diabetic diet recommendations, noncompliant with daily blood glucose checks and insulin administration. The patient did express willingness to change and was open to treatments.

In the case of Mr. Taleb’s main CC was “”I have been sick for the past three or four days. It started with my throat being scratchy and lots of sneezing. Now my nose is all stopped up, and I’m blowing it constantly. I’m also coughing a lot.” For Mr. Taleb it was important to ask questions to determine the onset and duration of his symptoms, risk factors, any relevant symptoms he has had. The patient’s answers revealed that he had been exposed to his sick children; he was a smoker, no fevers, rhinitis, sore throat, non-productive cough present at night, lack of chest pain, myalgias, weight loss, hemoptysis or dyspnea.

What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis? In Case 1 the key components of the physical exam should include, fundoscopic examination, foot exam, neurologic, abdomen, and cardiac systems. In the case of Mr. Morales he presented with blurry vision which can indicate diabetic retinopathy. Diabetic retinopathy is a common microvascular complication of type 1 and type 2 diabetes affecting over 3 million people globally (Dugan, J.2017). Glycemic control is necessary to the prevention of diabetic retinopathy. Assessing for skin integrity and foot ulcers is imperative in diabetics.

For case 2, Mr. Taleb’s physical exam should include visual examination of the throat, as well as a full HEENT exam. This is important to determine if his cold symptoms are bacterial or viral. Assessing for fevers, productive or nonproductive cough, and lung sounds are necessary to determine whether antibiotics are warranted. Mr. Taleb had not fevers and had clear drainage, antibiotics were not warranted.

Which differential diagnosis is to be considered with each case study? What was your final diagnosis? For Mr. Morales the most likely differential diagnoses include Diabetes Mellitus Type II, uncontrolled Hyperglycemia, uncontrolled hypertension, dyslipidemia. My final diagnosis for Mr. Morales would be Diabetes Mellitus Type II. Mr. Morales did originally present to the hospital with a non-ST elevation myocardial infarction and required three vessel coronary artery bypass grafting, but his present issue to his PCP was uncontrolled diabetes.

For Mr. Taleb URI, allergic rhinitis, and acute bronchitis were the most likely diagnosis. Do not use antibiotics for uncomplicated acute bronchitis in adults, regardless of duration of cough, due to modest benefit and potential harms (Petrovic,M.S. (2019). A viral upper respiratory infection was my final diagnosis. The patient did not present with a fever, productive cough which ruled out pneumonia. The throat was not very red with no exudates, no purulent nasal discharge, sinus tenderness, ruling out strep throat, sinus infection is unlikely. Antibiotics for uncomplicated acute bronchitis and URI in adults, regardless of duration of cough, due to modest benefit and potential harms are contraindicated (Petrovic,M.S. (2019).

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