C350 Ariela Tips

Problem List Recommendation Problem MSAP Ranking Acute dyspnea - Most Significant Active Problem Dry cough - Related Near syncope - Related Knee replacement 6 weeks ago - Related Current smoker: 80 pack-year history - Related Tachycardia – related Low blood pressure - Related Mild hypoxemia - Related Fever - Related Diabetes mellitus (type 2) - Related Obesity and sedentary lifestyle - Related Tachypnea - Related Recent 5-pound weight loss - Unrelated Problem List Feedback: The problem list allows you to begin to see the overall, or unified, constellation of significant signs and symptoms. It is also the starting point for developing, and then ranking, your diagnostic hypotheses. The pertinent presence or absence of other critical signs and symptoms will aid your assessment of the severity of the presenting complaint and your assessment of potential comorbidities. The medical problem list you have compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a "problem" in the true sense of the word. This study source was downloaded by from CourseH on :57:26 GMT -05:00 In this case, the most significant active problem (MSAP) is acute-onset dyspnea. The fact that the problem had such an acute onset is the single most important factor that should influence your thought process in developing a differential diagnosis. This problem is explained by her mild hypoxemia, measured on her finger pulse-oxygen measurement of 90%. Looking through the problem list, her complaint of near syncope or lightheadedness is best explained by hypotension, so these problems are linked also had an acute onset. Focusing on the acute aspects of the presentation, you should be considering problems in the heart and lungs that present acutely. For cardiac pathologies, it is important to look at her risk factors. She is postmenopausal, obese, sedentary and a long-time heavy smoker. Thus, she has markedly increased risk of developing cardiovascular disease. In this regard, it is important to remember that woman can have unusual presentations of MIs and that they can be “silent” or without pain in individuals with longstanding diabetes. Transient ischemia or angina can also be “silent” in patients with diabetes and can present with signs of acute onset congestive heart failure. Focusing on the pulmonary system, her recent knee surgery, obesity, smoking, sedentary lifestyle and diabetes, put her at risk for increased coagulation and pulmonary vascular occlusion. In addition, her 80 pack-year history of smoking gives her a 68 times higher risk spontaneous pneumothorax compared to nonsmokers. The non-productive cough and elevated temperature are usually associated with an infectious process, however, they can also be seen in cardio-pulmonary vascular problems that are suggested above. The patient's recent 5-pound weight loss, appears to be unrelated to the MSAP at this time. A larger weight loss that was unintentional would be worrisome for occult malignancy that could also increase her risk of coagulopathy. Problem Statement Recommendation: Mrs. Hernandez is a 64-year-old woman who presents with acute-onset severe dyspnea, non-productive cough, low-grade fever, and presyncopal symptoms. She is hypoxic (O2 saturation 90% on room air), has a normal heart and lung exam, but has bilateral lower leg edema, and right sided calf tenderness. Of note is a right knee replacement 6 weeks prior and a PMH significant for obesity, DM, HTN, 2 PPD smoking habit and a sedentary lifestyle since surgery. She has a family history of CAD.