A 72-year-old male arrives at the ER today with his daughter with complaints of weakness

A 72-year-old male arrives at the ER today with his daughter with complaints of weakness and shortness of breath over the past two days. He has a history of poor oral intake over the last three weeks due to financial difficulties and recent dental issues that have made chewing painful. What are your differential diagnoses for a patient with weakness and shortness of breath? Go through each body system and list possible etiologies that can cause these symptoms. You must have at least 2-3 differential diagnoses per body system. Neurological: 1. 2. 3. Cardiovascular: 1. 2. 3. Pulmonary: 1. 2. 3. Gastrointestinal: 1. 2. 3. Genitourinary: 1. 2. 3. Musculoskeletal: 1. 2. 3. Endocrine: 1. 2. 3. Psychiatric: 1. 2. 3. Metabolic: 1. 2. 3. Exogenous: 1. 2. 3. Next Step: Gather data to rule out or confirm potential causes of the symptoms. Patient presentation: You walk into the ER room and find the patient to be a thin, frail man appearing older than his stated age. He is in mild distress, with labored breathing and generalized weakness. His daughter reports that he has not been eating well, surviving mainly on tea, toast, and occasional canned soup. She also notes his legs seem swollen. He denies fever or recent infections but mentions feeling “shaky” after eating this morning. His daughter states he has lost at least 15 pounds over the past month. He denies any history of drug or alcohol use. PMH: Malnutrition, type 2 diabetes (diet controlled), hypertension, depression, and dental issues. PSH: None. FH: Father had coronary artery disease; mother had osteoporosis. SH: Retired factory worker, lives alone. Denies smoking or alcohol use. Allergies: NKDA. Medications: Lisinopril 10 mg PO daily and Sertraline 50 mg PO daily What are 3 pertinent positives from the information given so far? 1. 2. 3. What are 3 pertinent negatives from the information given so far? 1. 2. 3. Write the 1st paragraph of your HPI: ROS: The patient is a poor historian, with additional input from his daughter: Constitutional: Denies fever, chills. Endorses weight loss, fatigue, and poor appetite. HEENT: Denies vision changes, sore throat, or ear pain. Endorses difficulty chewing due to dental issues. CV: Denies chest pain or palpitations. Endorses lower extremity swelling. Pulmonary: Denies cough but endorses mild shortness of breath. GI: Denies nausea, vomiting, diarrhea, or abdominal pain. GU: Denies dysuria or hematuria. MSK: Denies recent falls. Endorses muscle weakness. Neuro: Denies confusion, numbness, or tingling. Endorses shakiness after eating. Endocrine: Denies polyuria, polydipsia, or heat/cold intolerance. Physical Exam: Vital signs: Temp 98.4??F, HR 110, BP 128/80 mmHg, RR 20, SpO2 95% on room air, blood glucose 78 mg/dL. Constitutional: Thin, frail, appears older than stated age. Mild respiratory distress. HEENT: PERRL, buccal mucosa dry, missing several teeth. CV: Tachycardic, no murmurs. 2+ bilateral lower extremity edema. Pulmonary: Clear to auscultation bilaterally. GI: Normal bowel sounds. No tenderness or distension. Neuro: Alert and oriented to person, not time or place. No focal deficits. Skin: Cool, dry, with poor turgor. No rashes or lesions. Based on ROS and PE, what are 3 pertinent positives? 1. 2. 3. Based on ROS and PE, what are 3 pertinent negatives? 1. 2. 3. Labs and Diagnostics: CBC: WBC: 8.5 Hgb: 11 HCT: 34 Platelets: 250 BMP: Na+: 138 K+: 2.8 Cl-: 98 CO2: 2 BUN: 30 Creatinine: 1.1 Glucose: 78 Phosphorus: 1.5 Magnesium: 1.2 LFT: ALT: 22 AST: 18 Albumin: 2.5 Urinalysis: Color: Clear Specific gravity: 1.010 Protein: Negative Glucose: Negative EKG: Sinus tachycardia, no acute ST changes. What did you discover to be abnormal with his labs? 1. 2. 3. 4. 5. Write out your Diagnosis/ Assessment and Treatment Plan: Diagnosis: Assessment: Plan: Does this patient need to be admitted to the hospital? Why or why not? What types of acute care patients are at an increased risk of developing this disorder that you diagnosed? 1. 2. 3. What is the most severe complication associated with this diagnosis that you should monitor regularly and why?

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