Miami Dade College 55 Year Old Homeless Man with Respiratory Symptoms Discussion

Case Study Chosen:

Mason, a 55-year-old homeless man with respiratory symptoms.

Demographics:

Age: 55 Gender: Male

Mason, a 55-year-old homeless man with respiratory symptoms and related findings from the examination, here are appropriate questions to ask Mason during the initial assessment:

1. General Health:Can you describe your overall health and any chronic medical conditions you are aware of?Are you currently taking any medications or have any known allergies to medications?Do you have a history of frequent colds or respiratory infections?
2. Respiratory Symptoms:When did you first notice the morning cough and frequent colds? How long have you experienced these symptoms?Can you describe the cough in more detail (productive/non-productive, color and consistency of sputum)?Have you noticed any triggers or specific activities that worsen your difficulty in breathing?
3. Smoking History:How long have you been smoking, and how many cigarettes do you smoke per day?Have you ever attempted to quit smoking, and if so, what strategies or treatments have you tried?
4. Physical Activity and Mobility:Can you elaborate on how your shortness of breath has progressed, especially with everyday activities? Are there specific activities that have become particularly challenging?How long have you experienced difficulty walking long distances, and has this affected your ability to find food and access resources?
5. Breathing Patterns and Symptoms:Have you noticed any changes in your breathing pattern, such as rapid breathing or increased effort to breathe?Do you experience chest pain or discomfort while breathing, especially during exertion or at rest?Have you ever been told that you make a sound when you breathe, like wheezing or whistling?
6. Cardiovascular Health:Have you ever been diagnosed with high blood pressure or other heart-related conditions?Do you experience any chest pain, palpitations, or irregular heartbeat?

SUBJECTIVE:

CC: Difficulty breathing and seeking medicine to help survive on the streets.

HPI:

• Subjective: Shortness of breath during physical activity, difficulty breathing with everyday activities, frequent morning cough, limited mobility due to breathlessness.

OBJECTIVE:

General:

• VS: 99°F, HR: 100 bpm, RR: 28/min, BP: 140/90 mmHg
• Weight, Height, BMI: Not available

Physical Exam Elements:

• Respiratory system: Distant breath sounds, end-expiratory wheezes, use of accessory muscles to breathe, slight barrel chest, neck vein distention.

POC Testing:

• None mentioned in the case study.

ASSESSMENT:

Working

(ICD-10):

• COPD

  (Chronic Obstructive Pulmonary Disease) – J44.9

Differential Diagnosis:

1. Asthma

   – J45.909

2. Acute Bronchitis

   – J20.9

PLAN:

Diagnostic studies:

• Pulmonary function tests (spirometry, lung volumes, diffusing capacity) for definitive COPD diagnosis.

Treatment:

• COPD Management:Inhaler therapy (e.g., salbutamol/albuterol, ipratropium)Smoking cessation counselingPulmonary rehabilitation referral

Referrals:

• Pulmonary specialist for further evaluation and management.

Education:

• Educate on COPD, smoking cessation, importance of medication compliance, and seeking medical care.

Health maintenance:

• Encourage regular follow-ups, adherence to medication and pulmonary rehabilitation programs, and annual influenza vaccination.

RTC (Return to Clinic):

• Follow up in 2 weeks to assess response to treatment and adjust the management plan as needed.

Diagnosis Table:

Pulmonary function tests (spirometry)

Clinical assessmentSymptomatic relief, rest, hydration

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