This document discusses a patient presenting with shortness of breath, cough, and fever. On examination, the patient has diminished breath sounds and rales. A chest x-ray shows an infiltrate in the right middle lobe. Potential diagnoses discussed include pneumonia, myocardial infarction, pulmonary embolism, congestive heart failure, and asthma. Pneumonia is considered the most likely based on symptoms and exam findings. References from 2013-2018 are provided to support the different diagnoses.

1. Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System
I need 1 reply comment to each post with a credible sources, citation and years above 2013
in APA format.Post 1CHIEF COMPLAINT: Shortness of Breath and coughSubjective: Pt
presents with complaints of shortness of breath and productive cough. Pt relates he is
coughing up thick green sputum with occasional bloody sputum. Pt relates that he has
increased shortness of breath with walking. Patient relates that he is also short of breath at
rest. Pt also relates that he has had some chills and sweats and felt like he may have a
fever. He states that he has taken Tylenol for those symptoms. Objective: Temperature
100.9, Respiratory rate 20, Heart rate 82, Blood pressure right arm 128/70, Oxygen
saturation 89% on room air, Weight 210 pounds, EKG shows normal sinus rhythm, Chest
radiographAssessment: Skin is warm and moist. Thorax is symmetrical with diminished
breath sounds with rales and expiratory wheezes throughout, negative for rhonchi. Wet
productive cough noted during exam. Heart is regular sinus rhythm with rate of 82. Good
S1, S2; negative S3 or S4 and negative for murmur. Abdomen protuberant with normoactive
bowel sounds auscultated in all four quadrants. No pedal edema noted. 2+ dorsalis pedis
pulses bilaterally. Neurologic: Patient is awake, alert and oriented to person, place and time.
Chest radiograph shows infiltrate in the right middle lobe. Priority diagnosis includes 1.
Pneumonia 2. Myocardial Infarction 3. Pulmonary embolism 4. Congestive Heart Failure 5.
Asthma1. Pneumonia: The patient presents with productive cough and shortness of breath
with exertion. Patient has elevated temperature and low oxygen saturations along with
diminished breath sounds, rales and expiratory wheezes which are all consistent symptoms
with community acquired pneumonia. (Lynn, 2017). Chest radiograph shows right middle
lobe infiltrate which is also consistent with pneumonia. (Kaysin and Viera, 2016). 2.
Myocardial Infarction: The patient presents with shortness of breath and low oxygen
saturations. Pt states that his shortness of breath is worse with exertion but is present at
rest also. Dyspnea is a frequent associated symptom with MI. (Lawesson, Thylen, Ericsson,
Swahn, Isaksson and Angerud, 2018). The patient did have an EKG completed that revealed
a normal sinus rhythm at a rate of 80 with no obvious signs of ectopy. Evaluation of
troponin level would assist in ruling out MI as a diagnosis for this patient. (Berliner,
Schneider, Welte and Bauersachs, 2016). 3. Pulmonary Embolism: Dyspnea is the primary
symptom for patients with PE. (Garcia-Sanz, Pena-Alvarez, Lopez-Landeiro, Bermo-
Dominguez, Fonturbel and Gonzalex-Barcala, 2014). Onset of dyspnea with PE is typically
sudden and further history for this patient related to onset of symptoms. Evaluation of any
extremity pain and swelling, D-dimer or chest angiography would also assist in determining

2. if this was a more likely diagnosis. (Berliner, Schneider, Welte and Bauersachs, 2016).4.
Congestive Heart Failure: Dyspnea is also a common symptom with congestive heart
failure. Fatigue, diminished exercise tolerance and fluid retention are also common
symptoms of CHF. (Berliner, Schneider, Welte and Bauersachs, 2016). The patient has rales
noted upon auscultation which could be consistent with congestive heart failure however
coupled with the remainder of the exam including productive cough with thick green
sputum and fever, CHF would not be the primary diagnosis. Further evaluation of
extremities of abdomen and extremities for signs of fluid retention would be indicated as
well as labs such as BNP. 5. Asthma: The patient has expiratory wheezes and shortness of
breath which are both consistent with asthma; however the patient also has fever and
productive cough which are not consistent asthma symptoms. (Huether and McCance,
2017). Plan: Not indicatedReferencesArcangelo, V. P., Peterson, A. M., Wilbur, V. & Reinhold,
J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th
ed.). Ambler, PA: Lippincott Williams & Wilkins.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO:
Elsevier Mosby. Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The
Differential Diagnosis of Dyspnea. Deutsches Aerzteblatt International, 113(49), 834.
doi:10.3238/arztebl.2016.0834Debasis, D., & David C., H. (2009). Chest X-ray
manifestations of pneumonia. Surgery Oxford, (10), 453.
doi:10.1016/j.mpsur.2009.08.006Dains, J. E., Baumann, L. C., & Scheibel, P.
(2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St.
Louis, MO: Elsevier Mosby.García-Sanz, M., Pena-Álvarez, C., López-Landeiro, P., Bermo-
Domínguez, A., Fontúrbel, T., & González-Barcala, F. (2014). Original article: Symptoms,
location and prognosis of pulmonary embolism. Revista Portuguesa De
Pneumologia, 20194-199. doi:10.1016/j.rppneu.2013.09.006Post 2S:Chief Complaint: “I am
having chest pain at this time”History of Present Illness: Pleasant, Caucasian male
experiencing an acute onset of sharp, constant chest pain when taking a deep
breath. Denies any alleviating factors. Yesterday his wife noticed his RT leg was edematous
with erythema, denies any injury. Recently he returned from a vacation with an 8-hour
plane ride. The patient was not asked if his pain radiated or if he had nausea or
dizziness.Past Medical History: Denies taking any medications. Allergies, surgeries, past
medical conditions “not provided.” History of cancer or deep vein thrombosis not
provided.Social History: MarriedReview of symptoms:General: Feels short of breath when
taking a deep breath, also having sharp lower RT rib pain.Cardiovascular: Experiencing
tachycardia. Peripheral edema started yesterday in RT lower leg.Pulmonary: Reports having
sharp pain when taking a deep breath with no relief measures noted. Complains of dyspnea
with productive hemoptysis cough this morning. Gastrointestinal: “not
provided.”O:VS: BP 148/88 RT arm; P 112 and irregular; R 32 and labored; T 97.9 orally;
Pulse Ox 90% on RA; His current weight is stable at 210 pounds.General: Well-nourished, a
well developed Caucasian male who is alert and cooperative. He is a good historian and
answers questions appropriately. Patient sitting upright at the side of the cot appears
anxious with labored breathing. Guarding noted in the anterior, distal RT rib
area.Cardiovascular: Skin is pallor, cool and diaphoretic. Heart rate is tachycardic. S1 and S2

3. irregular with no S3, S4, or murmur auscultated. RT calf with erythema, 2+ edema, warmth,
and tender with palpation. LT leg with no edema, tenderness, or erythema noted. Bilateral
2+ dorsalis pedis pulse. Telemetry showing a sinus arrhythmia.Gastrointestinal:
Protuberant abdomen with active bowels x 4 quadrants.Pulmonary: LT Lung clear to
auscultation, RT middle and lower lobes with diminished breath sounds. No rales, rhonchi,
or wheezing auscultated. Respirations labored. Respiratory excursion
symmetrical.Diagnostic results: CXR, ECG, venous doppler studies and ultrasound for DVT,
V/Q scan, CT of the chest, labs- sputum culture, cardiac enzymes. Telemetry.A:Differential
Diagnosis:1.) Pulmonary Embolism2.) Pneumonia3.) Lung Cancer4.) Myocardial
Infarction5.) Cardiac ArrythmiaP: “not required”Evidence and Justification of Differential
Diagnosis and Diagnostic TestsGruettner J. et al. (2015) report the Wells risk score assesses
the history of a previousDVT or PE in a patient. Assessment of tachycardia, recent surgeries
or immobilization,observation of DVT signs, an alternative diagnosis less likely than
pulmonary embolism,hemoptysis, and cancer are gathered. Each area is assigned a score
and the calculated total scoreinterprets the probability of having a pulmonary embolism.
The patient calculated scoreindicated a pulmonary embolism even though the history of
cancer was unknown.The diagnostic test of a CT angiography was found to be successful in
the diagnosis of apulmonary embolism with Gruettner J. et al. (2015) research. The D-dimer,
ABG, EKG, andcomputed tomography showed little value in the diagnosis (Gruettner J. et al.,
2015).Dains, J. E., Baumann, L. C., & Scheibel, P. (2016) indicate pneumonia causes the