Module 3 – Airway Diseases – Plan

Module 3 – Airway Diseases – Plan of Care Differential Diagnosis Worksheet Case Scenario A 72-year-old female presents to the clinic with an acute onset of dyspnea. She had been outside tending to her flower garden during the summer afternoon hours. In addition, she complains of shortness of breath on exertion and worsening fatigue for the last few months. She does not complain of chest pain or tightness. She has noted worsening of foot and ankle swelling of both legs over past several months. She has a productive cough each morning but gets worse when she has a cold. She has a long-standing smoking history of one pack per day for the past 50 years and has been unwilling to quit. She has been previously diagnosed with breast cancer that was treated with lumpectomy and local radiotherapy. No recurrence at 6-month and one year follow up examinations. During an emergency room visit last year for an episode of shortness of breath, she was prescribed an albuterol inhaler. She has been treated for hypertension for the past 23 years. She was diagnosed with diabetes 10 years ago. Current medications: propranolol 80 mg twice daily (Hint: pay attention to this medication’s effect on bronchodilators) hydrochlorothiazide 25 mg daily metformin 500 mg twice daily On physical examination, her vital signs are as follows: Heart rate 76 bpm, Respiratory rate 30 bpm, and blood pressure 152/85 mmHg. Examination of her lungs revealed an expanded chest with distant breath sounds and faint wheezes diffusely. Heart sounds were normal. She lives alone in a rural farming community but has family close to her who visit weekly and help with house and yard work. She has two cats and one small house dog. She does not complain of any allergies. Lab Spirometry is performed, and the following values are obtained: Pre-Bronchodilator Post-Bronchodilator Predicted Measured % Measured % % change FVC 2.66 1.26 47 1.32 49 4 FEV1 2.02 0.50 25 0.54 27 8 FEV1/FVC 76 39 51 41 54 6 PEF 315 114 36 120 38 5 FEF 25-75 1.82 0.18 10 0.19 10 0 Chest Radiograph: Arterial Blood Gas (on room air): pH 7.29 PaCO2 76 mmHg PaO2 44 mmHg HCO3 38 mEq/L SpO2 83% Medical History: Vital Signs: Extremities: Chest: Lungs: Diagnostics Chest X-ray: PFTs: ABGs: Other: Risk Factors 1. 2. 3. 4. 5. Diagnostic Criteria Key Indicators 1. 2. 3. 4. 5. Problem Representation Differential Diagnosis (Initial List) Cardiac Non-Cardiac Differential Diagnosis (Final List) Most likely: Can’t miss: Less likely: Least likely: What are your background questions? List references of sources consulted. (Hint: background questions are those that ask for general information to fill in any knowledge gaps about a topic such as what is the disorder; what causes it; how does it present; what are some treatment options. These questions can be answered by using “background” resources such as textbooks and narrative reviews in journals which give a general overview of the topic.) ASK – PICO (You can refer back to the Module 1 – Differential and PICO Resources page for help with creating your PICO) Patient/population/problem: Intervention (treatment/therapy) Comparison, if any (treatment/therapy) Outcome (likelihood on patient important outcomes) State your foreground question. (Hint: foreground questions are those that can be answered from scientific evidence about diagnosing, treatment, and prognosis – use the components of your PICO.) Acquire What study type is best suited for answering this type of question? Check all that apply. Case control Meta-analysis Cohort Clinical practice guideline Randomized controlled trial Other: Systematic review Other: What resources did you use to conduct your search? Check all that apply. PubMed Web of Science CINAHL Google Scholar Cochrane (CENTRAL) Other: Cochrane (CDSR) Other: Provide your search strategy. Be sure to include important keywords and MeSH terms – list significant words, phrases, and subject headings. List Boolean operators uses. You can copy the relevant search(es) from the “History” tab. List the article(s) that you appraised. Limit to 2-3 articles. Appraise To what extent are the results valid for each study? Points of discussion should include: a description of the study population, study methodology, treatments and outcomes measured, assessment of follow-up (i.e. sufficiently long and complete?). You can list the articles separately or synthesize the information – make note of which option. What are the study’s results for each study? Point of discussion should include a comprehensive description of the study findings, including key statistical findings. You can list the articles separately or synthesize the information – make note of which option. To what extent can I apply the results to my “patient”? Points of discussion should include an assessment of whether your “patient” is different or similar than those in the study or studies. Apply – Present your recommendations as if you are talking with your patient. Use simple, non-technical words. Explain the nature of the patient’s complaint, what options are available, and, based on the evidence, the strengths and weaknesses of each option to help the “patient” make an informed decision. Remember to consider all aspects of the patient’s care. Are there other disease conditions that need to be addressed? Do you have recommendations on medication changes, lifestyle changes, additional testing, etc? Assess – How would you assess the outcomes of your recommended plan of care? Discuss as if you are talking with your patient.

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