Case Study Chosen: Mason, a 55-year-old homeless man with respiratory symptoms.

Case Study Chosen:
Mason, a 55-year-old homeless man with respiratory symptoms.
Demographics:
Age: 55 Gender: Male
Mason, a 55-year-old homeless man with respiratory symptoms and related findings from the examination, here are appropriate questions to ask Mason during the initial assessment:
General Health:Can you describe your overall health and any chronic medical conditions you are aware of?
Are you currently taking any medications or have any known allergies to medications?
Do you have a history of frequent colds or respiratory infections?
Respiratory Symptoms:When did you first notice the morning cough and frequent colds? How long have you experienced these symptoms?
Can you describe the cough in more detail (productive/non-productive, color and consistency of sputum)?
Have you noticed any triggers or specific activities that worsen your difficulty in breathing?
Smoking History:How long have you been smoking, and how many cigarettes do you smoke per day?
Have you ever attempted to quit smoking, and if so, what strategies or treatments have you tried?
Physical Activity and Mobility:Can you elaborate on how your shortness of breath has progressed, especially with everyday activities? Are there specific activities that have become particularly challenging?
How long have you experienced difficulty walking long distances, and has this affected your ability to find food and access resources?
Breathing Patterns and Symptoms:Have you noticed any changes in your breathing pattern, such as rapid breathing or increased effort to breathe?
Do you experience chest pain or discomfort while breathing, especially during exertion or at rest?
Have you ever been told that you make a sound when you breathe, like wheezing or whistling?
Cardiovascular Health:Have you ever been diagnosed with high blood pressure or other heart-related conditions?
Do you experience any chest pain, palpitations, or irregular heartbeat?
SUBJECTIVE:
CC: Difficulty breathing and seeking medicine to help survive on the streets.
HPI:
Subjective: Shortness of breath during physical activity, difficulty breathing with everyday activities, frequent morning cough, limited mobility due to breathlessness.
OBJECTIVE:
General:
VS: 99°F, HR: 100 bpm, RR: 28/min, BP: 140/90 mmHg
Weight, Height, BMI: Not available
Physical Exam Elements:
Respiratory system: Distant breath sounds, end-expiratory wheezes, use of accessory muscles to breathe, slight barrel chest, neck vein distention.
POC Testing:
None mentioned in the case study.
ASSESSMENT:
Working Diagnosis (ICD-10):
COPD (Chronic Obstructive Pulmonary Disease) – J44.9
Differential Diagnosis:
Asthma – J45.909
Acute Bronchitis – J20.9
PLAN:
Diagnostic studies:
Pulmonary function tests (spirometry, lung volumes, diffusing capacity) for definitive COPD diagnosis.
Treatment:
COPD Management:Inhaler therapy (e.g., salbutamol/albuterol, ipratropium)
Smoking cessation counseling
Pulmonary rehabilitation referral
Referrals:
Pulmonary specialist for further evaluation and management.
Education:
Educate on COPD, smoking cessation, importance of medication compliance, and seeking medical care.
Health maintenance:
Encourage regular follow-ups, adherence to medication and pulmonary rehabilitation programs, and annual influenza vaccination.
RTC (Return to Clinic):
Follow up in 2 weeks to assess response to treatment and adjust the management plan as needed.
Diagnosis Table:
Diagnosis
Signs/Symptoms
Gold Standard Diagnostics
Gold Standard Treatment
COPD
Difficulty breathing, chronic cough, distant breath sounds
Pulmonary function tests (spirometry)
Inhaler therapy (bronchodilators), corticosteroids, oxygen therapy
Community Acquired Pneumonia
Cough, shortness of breath, fever, chest pain, productive cough, fatigue
Chest X-ray, sputum culture, blood tests
Antibiotics (based on pathogen and susceptibility), supportive care
Atypical Pneumonia
Cough, fever, headache, myalgia, non-productive cough
Chest X-ray, PCR, blood tests
Antibiotics (macrolides, fluoroquinolones), supportive care
Acute Bronchitis
Cough, sputum production, chest discomfort
Clinical assessment
Symptomatic relief, rest, hydration
Asthma
Shortness of breath, wheezing, coughing
Pulmonary function tests (spirometry)
Inhaler therapy (bronchodilators), corticosteroids, allergen avoidance
Tuberculosis
Cough, hemoptysis, weight loss, night sweats, fatigue
Chest X-ray, sputum culture, TB skin test
Antibiotics (multiple drugs for a specific duration), directly observed therapy (DOT)
Pulmonary Emboli
Shortness of breath, chest pain, cough, hemoptysis
CT pulmonary angiography, D-dimer
Anticoagulant therapy (heparin, warfarin, DOACs)
COVID-19
Fever, cough, shortness of breath, fatigue, loss of taste or smell
RT-PCR of respiratory samples
Supportive care, oxygen therapy, antiviral drugs (e.g., remdesivir)
Upper Respiratory Infection
Nasal congestion, sore throat, cough, fatigue
Clinical assessment
Symptomatic relief, rest, hydration
Influenza
Fever, chills, sore throat, muscle aches, fatigue
Rapid influenza diagnostic tests
Antiviral drugs (oseltamivir, zanamivir), supportive care