• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. 
• All replies must be constructive and use literature where possible. They must be at least 100 words and supported by at least one source. 

Your assignment will be graded according to the grading rubric.

REPLY #1

A differential diagnosis involves considering multiple diagnoses with similar signs and symptoms to determine which could be the likely cause of the patient’s presenting illness. When determining a diagnosis, the clinician must first get a thorough past and present medical history. Also, further assessment and diagnostics would be necessary to confirm any diagnosis. Some of the diagnostics include chest x-ray, EKG, lab work, etc. as well as a full physical assessment. Based on the findings presented in this case study, this author would further investigate the following potential diagnoses:

Pneumonia: Pneumonia is described as an infection in the lung. Common symptoms associated with pneumonia include productive cough, fever, shortness of breath, tachypnea, and pain with deep breathing (Zambare and Thalkari, 2019). Symptoms of severe pneumonia may include tachycardia, confusion, and hypoxia. Based on the information presented, the patient likely could have a pneumonia because she presents with shortness of air, discomfort with deep breathing, and low-grade fever. She also reports a productive cough. Patient is at greater risk for developing a pneumonia related to her long history of smoking. The cause of the pneumonia is likely viral as they tend to develop over several days where bacterial pneumonias have a more rapid onset (Zambare and Thalkari, 2019).

Congestive heart failure (CHF): The Mayo Clinic describes congestive heart failure as a condition in which the heart is not able to pump blood as efficiently as it should (2023). Some common symptoms this presents is shortness of breath, frothy sputum, tachycardia, chest pain, and swelling. This patient reports she is having increased difficulty breathing when laying down. One hallmark symptom of CHF is paroxysmal nocturnal dyspnea which is described as shortness of breath at nighttime when lying flat. This condition is usually alleviated when sitting upright. This patient also has predisposing factors of CHF, such as hypertension and history of smoking.

COPD exacerbation: COPD is a chronic lung disease that is characterized by progressive lung obstruction (Venkatesan, 2023). A COPD exacerbation presents as an increase in dyspnea, productive cough, tachypnea, and tachycardia. These exacerbations can be influenced by infectious processes, as well as environmental insults to the airway. This patient could be experiencing a COPD exacerbation related to the presentation of increased shortness of breath, tachycardia, and low-grade fever. Patient is at risk for COPD related to long term smoking history.

Pulmonary Embolism: Pulmonary embolisms are a blockage in the pulmonary arteries, usually as a result of a dislodged deep vein thrombosis (Gromadziński et al., 2023). There can be other forms of pulmonary embolism including air and fat emboli. This disease typically presents as shortness of breath (especially with exertion), dizziness, cough with bloody sputum, and sharp chest pain. This could potentially be a concern for this patient related to her new onset of shortness of breath and discomfort with breathing. History of smoking and oral contraceptive use presents as risk factors for the development of a pulmonary embolus.

            Once a definitive diagnosis is reached, appropriate treatment can be determined. Other considerations may include possibility of adverse reaction to newly prescribed medications.

References:

GromadziÅ„ski, L., Paukszto, Ł., Lepiarczyk, E., SkowroÅ„ska, A., Lipka, A., Makowczenko, K. G., ŁopieÅ„ska-Biernat, E., JastrzÄ™bski, J. P., Holak, P., SmoliÅ„ski, M., & Majewska, M. (2023). Pulmonary artery embolism: Comprehensive transcriptomic analysis in understanding the pathogenic mechanisms of the disease. BMC Genomics, 24(1). https://doi.org/10.1186/s12864-023-09110-0 

Mayo Foundation for Medical Education and Research. (2023, April 20). Heart failure. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142Links to an external site. 

Venkatesan, P. (2023). Gold COPD report: 2023 update. The Lancet Respiratory Medicine, 11(1), 18. https://doi.org/10.1016/s2213-2600(22)00494-5 

Zambare, K. K., & Thalkari, A. B. (2019). Overview on pathophysiology of pneumonia. Asian Journal of Pharmaceutical Research, 9(3), 177. https://doi.org/10.5958/2231-5691.2019.00028.5 

REPLY #2

Case Scenario – 47-year-old female who came to the emergency room complaining of dyspnea for the past 3 days. Complains that her symptoms became worse today and are exacerbated when she lays back and tries to take in a deep breath. Patient denies chest pain but has discomfort radiating from chest to back. Patient reports no changes in weight and is unaware of any family medical history. Patient is a former smoker with a 10-pack year history who quit 4 years ago. She states that she had a headache yesterday that has progressively gotten worse. She states she noticed a slight productive cough today. Patient was started on lisinopril and atorvastatin a week ago and her medical history consists of GERD, depression, hyperlipidemia, and hypertension. Her latest vitals were as follows: heart rate – 113, respiratory rate – 18, blood pressure – 113/83, O2 – 91% on room air, temperature – 37.9 C°, weight – 89.4 kg, and height – 66 inches. Patient’s current medications are as follows: Omeprazole 20mg PO daily, Sertraline 100mg PO daily, Chlorthalidone 25mg PO daily, Atorvastatin 40mg PO daily, Lisinopril 10mg PO daily, Ethinyl estradiol and norethindrone 1 tablet PO daily.

Based on the patient’s current symptoms, there are several different potential diagnoses for the 47-year-old female who presented in the ER. My top four likely diagnosis includes: Pulmonary embolism, pneumonia, chronic obstructive pulmonary disease (COPD), and an adverse effect of her lisinopril treatment.

Pulmonary Embolism

Based on the patient’s given symptoms of shortness of breath (worsening when laying back) and chest discomfort, there is a significant concern for pulmonary embolism. Additionally, given the patients 10-pack year smoking history, medication regimen (including oral contraceptives and lisinopril), and current tachycardia she is at greater risk of clot formation. With her O2 saturation at 91% on room air, concern that a pulmonary embolus is the likely cause is high. According to Morrone & Morrone (2018), clinical presentation of pulmonary embolus symptoms includes dyspnea, tachypnea, tachycardia, and chest pain. Based on her current vitals and symptoms and severity of this possibility should be considered and/or ruled out.

Pneumonia 

Pneumonia is another likely diagnosis as her symptoms present with a productive cough, feeling shortness of breath, and 37.9 C° fever. Additionally, her fever could be indicative of an inflammatory response causing her underlying symptoms. This diagnosis should be considered as clinical signs for this condition include chest pain, fever, low oxygen levels, and shortness of breath (NHLBI, 2022). Additional information and diagnostic exams will be needed to proceed with this diagnosis; however, it should be considered due to her clinical presentation and recent symptoms.

Chronic Obstructive Pulmonary Disease (COPD)

Based on the patient’s 10-pack year history, COPD should be considered as her history puts her at significant risk of developing the disease. Her presenting symptoms also align with classic signs of COPD such as shortness of breath, cough, and chest tightness. Although COPD is progressive, patients may experience acute exacerbations due to various factors such as respiratory tract infections and/or environmental factors. Classic symptoms of this disease include frequent coughing or wheezing, a productive cough with phlegm or sputum, shortness of breath, and difficulty breathing (CDC, 2022). It is important to consider COPD as it can cause significant respiratory compromise, especially in individuals with underlying lung conditions and a history of smoking.

Lisinopril Adverse Effect

After reviewing the patient’s recent medication list lisinopril poses a likely cause to her developing symptoms. Lisinopril is a strong inhibitor of the angiotensin-converting enzyme preventing the conversion of angiotensin I to angiotensin II, which acts as a vasoconstrictor (Olvera et al., 2022). Additional pharmacodynamics of the medication include a slight increase in potassium; however, this increase in some patients may cause hyperkalemia which is associated with cardiac abnormalities. Since the patient was recently prescribed this medication, the possibility of having adverse reaction should be considered. Additionally, lisinopril has several possible adverse reactions including dry cough, angioedema, hypotension, dizziness, headache, and renal insufficiency (Olvera et al., 2022). With the patients presenting symptoms, suspicion that her recent medication change is the trigger should be considered.

References

Centers for Disease Control and Prevention. (2022). COPD: Symptoms, Diagnosis, and Treatment. Retrieved from https://www.cdc.gov/copd/features/copd-symptoms-diagnosis-treatment.html

Morrone, D., & Morrone, V. (2018). Acute Pulmonary Embolism: Focus on the Clinical Picture. Korean circulation journal, 48(5), 365–381. https://doi.org/10.4070/kcj.2017.0314Links to an external site.

National Heart, Lung, and Blood Institute. (2022). Pneumonia. Retrieved from https://www.nhlbi.nih.gov/health/pneumoniaLinks to an external site.

Olvera Lopez, E., Parmar, M., Pendela, V. S., et al. (2023). Lisinopril. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482230/

Edited by Bradley Zolke on May 25 at 11:57pm

• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. 
• All replies must be constructive and use literature where possible. They must be at least 100 words and supported by at least one source. 

Your assignment will be graded according to the grading rubric.

REPLY #1

A differential diagnosis involves considering multiple diagnoses with similar signs and symptoms to determine which could be the likely cause of the patient’s presenting illness. When determining a diagnosis, the clinician must first get a thorough past and present medical history. Also, further assessment and diagnostics would be necessary to confirm any diagnosis. Some of the diagnostics include chest x-ray, EKG, lab work, etc. as well as a full physical assessment. Based on the findings presented in this case study, this author would further investigate the following potential diagnoses:

Pneumonia: Pneumonia is described as an infection in the lung. Common symptoms associated with pneumonia include productive cough, fever, shortness of breath, tachypnea, and pain with deep breathing (Zambare and Thalkari, 2019). Symptoms of severe pneumonia may include tachycardia, confusion, and hypoxia. Based on the information presented, the patient likely could have a pneumonia because she presents with shortness of air, discomfort with deep breathing, and low-grade fever. She also reports a productive cough. Patient is at greater risk for developing a pneumonia related to her long history of smoking. The cause of the pneumonia is likely viral as they tend to develop over several days where bacterial pneumonias have a more rapid onset (Zambare and Thalkari, 2019).

Congestive heart failure (CHF): The Mayo Clinic describes congestive heart failure as a condition in which the heart is not able to pump blood as efficiently as it should (2023). Some common symptoms this presents is shortness of breath, frothy sputum, tachycardia, chest pain, and swelling. This patient reports she is having increased difficulty breathing when laying down. One hallmark symptom of CHF is paroxysmal nocturnal dyspnea which is described as shortness of breath at nighttime when lying flat. This condition is usually alleviated when sitting upright. This patient also has predisposing factors of CHF, such as hypertension and history of smoking.

COPD exacerbation: COPD is a chronic lung disease that is characterized by progressive lung obstruction (Venkatesan, 2023). A COPD exacerbation presents as an increase in dyspnea, productive cough, tachypnea, and tachycardia. These exacerbations can be influenced by infectious processes, as well as environmental insults to the airway. This patient could be experiencing a COPD exacerbation related to the presentation of increased shortness of breath, tachycardia, and low-grade fever. Patient is at risk for COPD related to long term smoking history.

Pulmonary Embolism: Pulmonary embolisms are a blockage in the pulmonary arteries, usually as a result of a dislodged deep vein thrombosis (Gromadziński et al., 2023). There can be other forms of pulmonary embolism including air and fat emboli. This disease typically presents as shortness of breath (especially with exertion), dizziness, cough with bloody sputum, and sharp chest pain. This could potentially be a concern for this patient related to her new onset of shortness of breath and discomfort with breathing. History of smoking and oral contraceptive use presents as risk factors for the development of a pulmonary embolus.

            Once a definitive diagnosis is reached, appropriate treatment can be determined. Other considerations may include possibility of adverse reaction to newly prescribed medications.

References:

GromadziÅ„ski, L., Paukszto, Ł., Lepiarczyk, E., SkowroÅ„ska, A., Lipka, A., Makowczenko, K. G., ŁopieÅ„ska-Biernat, E., JastrzÄ™bski, J. P., Holak, P., SmoliÅ„ski, M., & Majewska, M. (2023). Pulmonary artery embolism: Comprehensive transcriptomic analysis in understanding the pathogenic mechanisms of the disease. BMC Genomics, 24(1). https://doi.org/10.1186/s12864-023-09110-0 

Mayo Foundation for Medical Education and Research. (2023, April 20). Heart failure. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142Links to an external site. 

Venkatesan, P. (2023). Gold COPD report: 2023 update. The Lancet Respiratory Medicine, 11(1), 18. https://doi.org/10.1016/s2213-2600(22)00494-5 

Zambare, K. K., & Thalkari, A. B. (2019). Overview on pathophysiology of pneumonia. Asian Journal of Pharmaceutical Research, 9(3), 177. https://doi.org/10.5958/2231-5691.2019.00028.5 

REPLY #2

Case Scenario – 47-year-old female who came to the emergency room complaining of dyspnea for the past 3 days. Complains that her symptoms became worse today and are exacerbated when she lays back and tries to take in a deep breath. Patient denies chest pain but has discomfort radiating from chest to back. Patient reports no changes in weight and is unaware of any family medical history. Patient is a former smoker with a 10-pack year history who quit 4 years ago. She states that she had a headache yesterday that has progressively gotten worse. She states she noticed a slight productive cough today. Patient was started on lisinopril and atorvastatin a week ago and her medical history consists of GERD, depression, hyperlipidemia, and hypertension. Her latest vitals were as follows: heart rate – 113, respiratory rate – 18, blood pressure – 113/83, O2 – 91% on room air, temperature – 37.9 C°, weight – 89.4 kg, and height – 66 inches. Patient’s current medications are as follows: Omeprazole 20mg PO daily, Sertraline 100mg PO daily, Chlorthalidone 25mg PO daily, Atorvastatin 40mg PO daily, Lisinopril 10mg PO daily, Ethinyl estradiol and norethindrone 1 tablet PO daily.

Based on the patient’s current symptoms, there are several different potential diagnoses for the 47-year-old female who presented in the ER. My top four likely diagnosis includes: Pulmonary embolism, pneumonia, chronic obstructive pulmonary disease (COPD), and an adverse effect of her lisinopril treatment.

Pulmonary Embolism

Based on the patient’s given symptoms of shortness of breath (worsening when laying back) and chest discomfort, there is a significant concern for pulmonary embolism. Additionally, given the patients 10-pack year smoking history, medication regimen (including oral contraceptives and lisinopril), and current tachycardia she is at greater risk of clot formation. With her O2 saturation at 91% on room air, concern that a pulmonary embolus is the likely cause is high. According to Morrone & Morrone (2018), clinical presentation of pulmonary embolus symptoms includes dyspnea, tachypnea, tachycardia, and chest pain. Based on her current vitals and symptoms and severity of this possibility should be considered and/or ruled out.

Pneumonia 

Pneumonia is another likely diagnosis as her symptoms present with a productive cough, feeling shortness of breath, and 37.9 C° fever. Additionally, her fever could be indicative of an inflammatory response causing her underlying symptoms. This diagnosis should be considered as clinical signs for this condition include chest pain, fever, low oxygen levels, and shortness of breath (NHLBI, 2022). Additional information and diagnostic exams will be needed to proceed with this diagnosis; however, it should be considered due to her clinical presentation and recent symptoms.

Chronic Obstructive Pulmonary Disease (COPD)

Based on the patient’s 10-pack year history, COPD should be considered as her history puts her at significant risk of developing the disease. Her presenting symptoms also align with classic signs of COPD such as shortness of breath, cough, and chest tightness. Although COPD is progressive, patients may experience acute exacerbations due to various factors such as respiratory tract infections and/or environmental factors. Classic symptoms of this disease include frequent coughing or wheezing, a productive cough with phlegm or sputum, shortness of breath, and difficulty breathing (CDC, 2022). It is important to consider COPD as it can cause significant respiratory compromise, especially in individuals with underlying lung conditions and a history of smoking.

Lisinopril Adverse Effect

After reviewing the patient’s recent medication list lisinopril poses a likely cause to her developing symptoms. Lisinopril is a strong inhibitor of the angiotensin-converting enzyme preventing the conversion of angiotensin I to angiotensin II, which acts as a vasoconstrictor (Olvera et al., 2022). Additional pharmacodynamics of the medication include a slight increase in potassium; however, this increase in some patients may cause hyperkalemia which is associated with cardiac abnormalities. Since the patient was recently prescribed this medication, the possibility of having adverse reaction should be considered. Additionally, lisinopril has several possible adverse reactions including dry cough, angioedema, hypotension, dizziness, headache, and renal insufficiency (Olvera et al., 2022). With the patients presenting symptoms, suspicion that her recent medication change is the trigger should be considered.

References

Centers for Disease Control and Prevention. (2022). COPD: Symptoms, Diagnosis, and Treatment. Retrieved from https://www.cdc.gov/copd/features/copd-symptoms-diagnosis-treatment.html

Morrone, D., & Morrone, V. (2018). Acute Pulmonary Embolism: Focus on the Clinical Picture. Korean circulation journal, 48(5), 365–381. https://doi.org/10.4070/kcj.2017.0314Links to an external site.

National Heart, Lung, and Blood Institute. (2022). Pneumonia. Retrieved from https://www.nhlbi.nih.gov/health/pneumoniaLinks to an external site.

Olvera Lopez, E., Parmar, M., Pendela, V. S., et al. (2023). Lisinopril. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482230/

Edited by Bradley Zolke on May 25 at 11:57pm