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Summary Recent Visit Analysis MS2.docx IHP-310 Milestone 2: Recent Visit Analysis IHP-310 SNHU Recent Visit Analysis Explain why the patient has returned to the doctors office. What symptoms and signs is the patient experiencing? Sally Pire has returned t€7,09
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Summary Recent Visit Analysis MS2.docx IHP-310 Milestone 2: Recent Visit Analysis IHP-310 SNHU Recent Visit Analysis Explain why the patient has returned to the doctors office. What symptoms and signs is the patient experiencing? Sally Pire has returned t
Recent Visit Analysis MS IHP-310 Milestone 2: Recent Visit Analysis IHP-310 SNHU Recent Visit Analysis Explain why the patient has returned to the doctors office. What symptoms and signs is the patient experiencing? Sally Pire has returned to Global Care Medical Center because she was havin...
recent visit analysis ms2docx ihp 310 milestone 2 recent visit analysis ihp 310 snhu recent visit analysis explain why the patient has returned to the doctors office what symptoms and signs
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Southern New Hampshire University
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IHP-310
Milestone 2: Recent Visit Analysis
IHP-310
SNHU
Recent Visit
Analysis
Explain why the patient has returned to the doctor’s office. What symptoms and
signs is the patient experiencing?
Sally Pire has returned to Global Care Medical Center because she was having shortness
of breath and dyspnea. She was having upper respiratory symptoms. She returned to work
and developed coughing, chills, fever, slight dyspnea with exertion, and sweats. Her
physical exam showed a fever was 102 with sweats. The doctor then decided to send the
patient for an x-ray to check her chest.
The chest x-ray showed an area of infiltrate on the right side which told the doctor
that it was acute pneumonia. She was then admitted to the hospital for further study and
treatment. When they did the repeat of the x-ray it showed pneumonia present in both
lungs that was clearing. They did a urinalysis, bloodwork, sputum culture, and a
cardiogram.
Analyze the new symptoms and signs to determine whether the past diagnosis is still
a reasonable conclusion or could have been a misdiagnosis. Use specific information
from both the recent visit and the patient history to inform your analysis.
On her previous visit she was seen due to problems with alcohol, gastritis due to
excessive alcohole intake, a fractured wrist and possible secondary injury due to excessive
, inebriation. The patient’s past signs and symptoms were angina, shortness of breath,
fluttering in her chest. weakness and fatigue, muscle cramps, constipation, Indigestion,
nausea, vomiting, and feeling of fullness in upper abdomen.
She was diagnosed with viral pneumonia upon admission before tests were ran. After
the tests were ran it showed bacteria in the sputum culture revealed a +1 enterobacter,
pointing to a bacterial pneumonia.
In this situation this could have been a misdiagnosis if patient hadn’t been admitted
for further tests. I feel the doctor came to a reasonable conclusion as he admitted her for
further testing when symptoms did not subside.
Based on the new signs, symptoms, and potential diagnosis (if the doctor has made a
new diagnosis), discuss what new or potential treatments would be appropriate.
Why?
With the new diagnosis she was given the appropriate medication of Ampicillin 500
milligrams four times a day and intermittent positive pressure breathing to treat the
pneumonia. She was continued on her Lanoxin, Lasix, and Klotrix medication. When her
fever would not drop, the doctor dropped the Ampicillin and changed it to Enalapril.
Enalapril was taken 4 times a day until her fever dropped and was gone for 48 hours. Upon
her discharge she was prescribed E-Mycin 333 mg three times daily, Afrin nasal spray, and
continuing her Lanoxin and Lasix.
A potential treatment that would help with all of her diagnosis including
atherosclerosis would be lifestyle changes. Eating a healthy diet and exercise would improve
her immune system[ CITATION May212 \l 1033 ]. Stopping smoking and drinking will help
improve all her medical conditions and help repair damages in her body and prevent it from
getting worse. I feel as though adding these things to the medication she is currently taking
would improve her lifestyle greatly.
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