I need 1 reply comment to each post with a credible sources, citation and years above 2013 in APA format.

Post 1

CHIEF COMPLAINT: Shortness of Breath and cough

Subjective:  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 radiograph

Assessment:  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. Asthma

1. 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 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 indicated

References

Arcangelo, 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.2016.0834

Debasis, D., & David C., H. (2009). Chest X-ray manifestations of pneumonia. Surgery Oxford, (10), 453. doi:10.1016/j.mpsur.2009.08.006

Dains, 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.2013.09.006

Post  2

S:

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: Married

Review 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 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 Embolism

2.) Pneumonia

3.) Lung Cancer

4.) Myocardial Infarction

5.) Cardiac Arrythmia

P: “not required”

Evidence and Justification of Differential Diagnosis and Diagnostic Tests

Gruettner J. et al. (2015) report the Wells risk score assesses the history of a previous

DVT 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 score

interprets the probability of having a pulmonary embolism. The patient calculated score

indicated 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 a

pulmonary embolism with Gruettner J. et al. (2015) research. The D-dimer, ABG, EKG, and

computed 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

Defining and Measuring Quality in Health Care Organizations   Quality is never an accident. It is always the result of intelligent effort. —John Ruskin  Quality is multidimensional and involves the perspectives of various stakeholders, including patients and families. As noted in this week’s Learning Resources, defining quality is not a simple, straightforward task. Yet, it provides an essential foundation for being able to measure and assess quality, and, ultimately, to improve it.  In this Discussion, you consider definitions and measurements of quality. As you proceed, think about why it is important for organizations to be able to quantify quality and compare current performance to previous performance, to a set of standards, and/or to performance in other organizations.   To prepare: •Review the information in the Learning Resources, especially the chapters in the Sadeghi, Brazi, Mikhail, and Shabot course text, focusing on how quality is or could be defined and measured. •Think about a health care organization with which you are familiar. It may be the same organization you are focusing on for your Course Project, or a different one. How do you think various stakeholders in this organization would define quality? How would you define quality as it relates to this organization? •Review the information on quality standards and / or aims in the Learning Resources, and consider the following: ◦Which outcomes related to quality are currently being monitored in the organization that you have selected? ◦How is related data collected and evaluated? ◦Does the organization use health information technology in this regard? If so, how? ◦How is quality-related information (e.g., data, needs for improvement) communicated throughout the organization? ◦What do you consider to be the strengths and weaknesses of the current approach to quality in this organization?

By Day 3  Post a definition of quality for your selected organization. Describe at least one quality-related measure that is currently being monitored within the organization.

Summarize the data collection process for this measure, and explain how this information is communicated to or among the staff. Identify at least one strength and one weakness related to how quality is defined, measured, and/or monitored within the organization.

Required Readings

Hickey, J. V., & Brosnan, C. A. (2017). Evaluation  of health care quality in for DNPs (2nd  ed.). New York, NY: Springer Publishing Company.

•Chapter 6, “Evaluating of Health Care Information Systems and Patient Care Technology” (pp. 143-170) This chapter examines federally mandated use of health information technology to improve health care and care delivery.   Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. (2013). Integrating quality and strategy in health care organizations. Burlington, MA: Jones & Bartlett Learning.

•Review Chapter 3, “General Concepts in Quality” (pp. 45–82) (assigned in Week 4)    The authors discuss historical perspectives of quality in various industries, and explain the multifaceted nature of defining quality in health care settings.     •Chapter 4, “Current State of Quality Measurement: External Dynamics” (pp. 83–98)    This chapter describes many of the government, nonprofit, and for-profit groups / organizations that contribute to the establishment quality standards and support research to improve the quality of health care.     •Chapter 5, “Current State of Quality Measurement: Internal Dynamics” (pp. 99–110)    This chapter focuses on mandatory and voluntary quality measurement in organizations.     •Chapter 6, “Measuring Quality of Inpatient Care” (pp. 111–132)    This chapter explains the terminology use in quality measurement (e.g., measures, indicators, metrics), and notes that measurement is a critical foundation for the ultimate aim of creating effective changes to improve quality.

•Chapter 8, “Quantifying the Quality Performance Gaps” (pp. 161–177)    This chapter addresses how to quantify current performance and set targets.   Epstein, J. N., Langberg, J. M., Lichtenstein, P. K., Kolb, R. C., & Stark, L. J. (2010). Sustained improvement in pediatricians’ ADHD practice behaviors in the context of a community-based quality improvement initiative. Children’s Health Care, 39(4), 296–311.  Retrieved from the Walden Library databases.     Researchers evaluate a quality improvement project on pediatric care of ADHD patients and the sustainability of the improvement over a two-year period.