Running head: DIFFERENTIAL DIAGNOSIS PAPER

Differential Diagnosis Paper

Presented to !her"l #uneau$ Dr% P&$ RN$ FNP'! T&E (NI)ERSIT* OF TE+AS S!&OOL OF N(RSING AT GAL)ESTON

In Partial Fulfill,ent Of the Re-uire,ents for the !ourse GNRS .//0 FNP Adult12o,en3s &ealth

4" Lisa 4a5er RN$ 4SN A,elie Gar6a RN$ 4SN

Fe7ruar" 18$ 9:1;

DIFFERENTIAL DIAGNOSIS PAPER

Introduction 2e ha<e =hosen a =lini=al =ase that presented >ith the s",pto, of =ough for our differential diagnosis paper% 2e >ill dis=uss the patient3s histor" and ph"si=al$ in=luding >hat the ideal histor" and ph"si=al >ould 7e$ identif" the three ,ost li5el" differential diagnosis$ and =o,pare and =ontrast s",pto,s% A differential diagnosis =hart for -ui=5 re<ie> of ,ost rele<ant su7?e=ti<e$ o7?e=ti<e$ and ph"si=al findings for ea=h diagnosis is also in=luded% 4ased on the top priorit" diagnosis$ >e >ill outline the plan of =are for our patient% History @rs% R# is a pleasant // "ear old >hite fe,ale that resides in &alletts<ille$ TeAas% She is neatl" groo,ed and appears health"% She states she is retired and ,arried$ has t>o gro>n =hildren li<ing in &ouston and )i=toria% She has signed ne> patient infor,ation for,s and updated =onta=t infor,ation% @rs% R# see,s to 7e a relia7le sour=e of infor,ation% &er =hief =o,plaint >as BI ?ust =an3t get rid of this =ough% I ha<e had it sin=e O=to7er% I also need ne> pres=riptions for ," insuran=e%C Analysis of symptoms: @rs% R#3s =ough 7egan in O=to7er after re=ei<ing <a==ines for Flu and Pneu,onia DPNAE% She reports an in=rease in =ough in De=e,7er$ >hen she >as diagnosed >ith an (pper Respirator" Infe=tion D(RIE% Clinician should have asked if she had more nasal congestion that made her cough with the URI. She re=ei<ed an anti7ioti= and Tessalon Pearls to assist >ith the =ough DA=ute 4ron=hitis$ )iral S"ndro,eE% She noted the =ough is usuall" >orse in the ,orning$ 7ut lasts all da"% Clinician should have asked her if the cough had changed in character since it began. NeAt$ she states her =ough is produ=ti<e$ =o,ing fro, her =hest and that the ,u=us is

DIFFERENTIAL DIAGNOSIS PAPER

thi=5$ =olor <ariation is >hite$ gra"$ or "ello>$ 7ut then turns =lears throughout the da" DA=ute 4ron=hitis$ )iral S"ndro,e$ Allergi= RhinitisE% She des=ri7es her =ough as a =ho5ing$ rasp"$ and ha=5ing DAllergi= Rhinitis$ A!E'I =oughE% Further$ she states =ough is anno"ing and is -uit se<ere in ,ornings and less during the da"$ 7ut does not 5eep her up at night DA=ute 4ron=hitis$ Allergi= RhinitisE% Clinician should have asked her if she had a sour taste in her mouth when she woke up. She reports so,eti,es her e"es >ater and dr" =old air and the air see,s to aggra<ate her =ough DAllergi= RhinitisE% @rs% R# states her =ough i,pro<es >ith a =ough drop$ throat lo6enge$ or Tessalon Pearls$ >hi=h see, to help 5eep it -uieter% She denies fe<er DA=ute 4ron=hitis$ Allergi= RhinitisE% Further$ she reports that her throat is irritated 7" the drainage fro, her nose DAllergi= RhinitisE$ and she has ,ild d"spnea >hen >al5ing o<er a ,ile DA=ute 4ron=hitisE% She reports that 7et>een =aring for her si=5 grand=hildren >ith flu in the past fe> >ee5s$ along >ith se<ent"'nine dail" <isits DPs"=hogeni= !ough r1t StressE to her ,other$ 7et>een the hospital for a !ongesti<e &eart Failure D!&FE eAa=er7ation and nursing ho,e pla=e,ent ,a" ha<e eAposed her to a =old or ger,s D)iral S"ndro,e$ Ps"=hogeni= !oughE% Lastl"$ she does report ha<ing a histor" of allergies DAllergi= RhinitisE and =edar =ounts are high this >ee5 and the pre<ious >ee5s% Current Health Status @rs% R#3s allergies >ere re<ie>ed prior to entering the patient roo,$ the" in=lude: Strepto,"=in$ Sulfa$ !odeine$ and Ni=5el% Strepto,"=in =auses s>elling of her e"es and throat$ !odeine =auses generali6ed it=hing$ and Ni=5el =auses a rash% NeAt$ her ,edi=ations >ere re<ie>ed% &er =urrent ,edi=ation list in=ludes: @etoprolol ER .:,g 4IDF !altrate /::,g G )it% D dail"F @ulti<ita,in dail"$ O,ega ; Fish Oil 1:::,g dail"$ Lisinopril 1:,g dail" DA!E'I Indu=ed !oughE$ !lonidine :%1,g PRN for s"stoli= 7lood pressure DS4PE greater than 18:F

DIFFERENTIAL DIAGNOSIS PAPER

4a=lofen 1:,g I to 1 ta7let at 7edti,eF Fa,otidine 9:,g at 7edti,e for Gastroesophageal RefluA Disease DGERDEF Flonase 9 spra"s ea=h nostril dail" DAllergi= RhinitisE$ Tessalon Pearls 1::,g 1'9 ta7lets TID D!oughE$ !restor 1:,g dail"F ASA 81,g dail"F Tu,s 9 ta7lets at 7edti,e DGERDE$ and Prilose= 9:,g dail" e<er" ,orning DGERDE% While the clinician did review the medication list with patient, she should have reviewed if the patient actually used the Flonase as prescribed. In practice, there are many patients that have medications for llergic Rhinitis, but only use them once they develop symptoms, instead of using them as a maintenance medication. All of her i,,uni6ations >ere up to date% &er ha7its in=lude a 7eer o==asionall"$ she denies s,o5ing throughout her life$ and denies using re=reational drugs% She does drin5s one =up of =offee e<er" ,orning and one glass of I=e tea >ith lun=h1dinner DGERDE% As for her diet she ,aintains a lo> salt diet$ =onsu,es <egeta7les$ li,its red ,eat to ; ti,es >ee5l"$ and eats fish and =hi=5en H da"s a >ee5% Lastl"$ she >al5s ;: ,inutes a da" outside DAllergi= RhinitisE and usuall" =o<ers 9 ,iles in that ti,e% At this point$ the =lini=ian leans to>ard A=ute 4ron=hitis 7e=ause of the des=ription of =ough$ sputu, produ=tion1=hara=teristi=s$ and re=ent (RI% )iral S"ndro,e >as eA=luded 7e=ause she3s not had fe<ers and the =lini=ian =an group her s",pto,s to diagnosis% &o>e<er$ 7e=ause her =ough started 7efore the (RI and it >as O=to7er$ the =lini=ian suspe=ts Allergi= Rhinitis at this ti,e% GERD =annot 7e eA=luded 7e=ause she has had a =ough for o<er 8 >ee5s and she >as as",pto,ati=% In addition$ she has had in=reased stressors$ >hi=h =an lead to in=reased a=id produ=tion in the sto,a=h% !he clinician also "uestions how closely she was able to maintain her diet due to spending so much time at the hospital with her mother. Relevant Past Medical History

DIFFERENTIAL DIAGNOSIS PAPER

@rs% R# reports her general health has 7een great sin=e getting 7lood pressure D4PE under =ontrol in @ar=h 9:19 for >hi=h she >as hospitali6ed% She states she pre<iousl" had eAtre,el" high 4P3s that finall" >ere =ontrolled >ith an A!E'I DA!E'I =oughE% Also she notes stress due to her ,other3s hospitali6ation >ith heart failure for se<ent"'nine da"s and re=ent ad,ission to a nursing ho,e DGERDE% She <isits her ,other dail" at the nursing ho,e% @rs% R# had an Esophagogastroduodenos=op" DEGDE >ith dilation% She states she >as as",pto,ati= >ith the stri=tures$ 7ut feels ,u=h 7etter DGERDE% &er ,edi=al histor" in=ludes &TN$ &"perlipide,ia$ &"pergl"=e,ia Ddiet =ontrolledE$ !olon Pol"ps$ Allergi= Rhinitis$ and GERD% A geriatri= s=reen >as perfor,ed$ >hi=h indi=ated that she had no defi=its$ she denied =ultural pra=ti=es that needed to 7e in=orporated into her =are% &er fa,il" histor" in=ludes !ere7ro<as=ular A==ident D!)AE$ !&F$ &TN$ &"perlipide,ia$ Rheu,atoid Arthritis DRAE$ and &"per=holesterole,ia% The =lini=ain as5ed @rs% R# >hat she thought >as =ausing her =ough$ she stated I ha<e this 7otherso,e =ough and it needs to goJ I don3t 5no> >h" I ha<e it% I =ough so hard so,eti,es at the nursing ho,e$ the nurses =o,e in the roo, and >orr" that it is ," ,other%C ROS of Relevant Systems: Head and neck: Denies head trau,a or histor" of head in?ur"% 2ears glasses$ notes so,e it=hing and e"e tearing DAllergi= RhinitisE$ denies heada=he$ last e"e eAa, No<e,7er 9:19% ars: Notes so,e popping noises DAllergi= RhinitisE% Denies tinnitus and states de=reased hearing fro, >or5ing in industrial air =onditioning shop "ears ago% !ose: Notes so,e =ongestion$ rhinorrhea$ s,elling inta=t DA=ute 4ron=hitis$ Allergi= RhinitisE% "hroat and Mouth: Throat feels s=rat=h"$ irritated and sore DAllergi= Rhinitis$ A=ute 4ron=hitisE% No dentation pro7le,s$ no sores% She notes that her <oi=e is hoarse DA=ute 4ron=hitis$ Allergi= Rhinitis$ GERDE% C#: &istor" of &TN$ no> =ontrolled DA!E'I =oughE$ no palpitations% Denies =hest pain and Peripheral )as=ular Disease DP)DE% Denies =laudi=ation and ede,a to 7ilateral

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lo>er eAtre,ities% Chest$%un&s: States she has a produ=ti<e =ough in the ,ornings and lasts throughout the da" DA=ute 4ron=hitis$ Allergi= RhinitisE% @u=us is >hite$ gra"$ and "ello> in =olor and thi=5% She states she 7egan feeling a 7urning sensation to her ,id =hest shortl" after her =ough 7egan DA=ute 4ron=hitisE% 'I: &istor" of GERD and stri=tures$ didn3t 5no> she had stri=tures until EGD$ 7ut feels ,u=h 7etter sin=e the" >ere dilated% %ymph: Denies% Physical (am )P * 'eneral +escription: Pleasant // "ear'old >hite fe,ale$ >ell groo,ed$ tal5ati<e$ and good historian% )ital signs: Te,perature: 08%;$ &eart Rate: /;$ Respirator" Rate: 1/ D00K on RAE$ 4P: 1;H1LL$ 2eight: 18. l7s%$ &eight: .3LC$ 4od" @ass IndeA D4@IE: 90% Physical (am: Head$!eck: Nor,o=ephali=1atrau,ati=$ hair ,ediu, teAture$ s5in >ith ,ini,al >rin5ling% Tenderness noted to right side of ne=5 upon palpation$ ,us=le tightness noted to trape6ius ,us=le >ith RO@% yes: 4oth e"es DO%(%E gloss"$ =on?un=ti<al in?e=tion$ no or7ital eAudate$ Pupils E-ual Round Rea=ti<e to Light and A==o,,odation DPERRLAE$ EAtra O=ular @us=les Inta=t DEO@IE and red refleA noted% !he clinician did not assess for allergic shiners# allergic salute. ars: Left t",pani= ,e,7rane DT@E translu=ent and light =one refleA noted% Slight er"the,a noted to right T@$ no 7ulging or fluid noted$ light =one refleA not noted DAllergi= Rhinitis M A=ute 4ron=hitis r1t pressure of =oughingE% !ose: Nasal er"the,a and s>elling present$ =lear nasal drainage DAllergi= Rhinitis$ A=ute 4ron=hitisE and tender frontal sinus pressure noted% Septu, is ,idline% "hroat$Mouth: No lesions or ,u=osal gro>ths noted% @e,7ranes ,oist and pin5$ posterior phar"nA er"the,atous DAllergi= Rhinitis$ A=ute 4ron=hitis$ GERDE >ith no eAudate noted% Tongue is ,idline and u<ula rises% Good dentition and teeth inta=t% C#: Good S1S9$ no ,ur,ur$ regular rate and rh"th, DRRRE$ point of ,aAi,al I,pulse DP@IE /8% Chest$%un&s: Lungs >ith audi7le =ra=5les and rhon=hi to 7ilateral lo>er lo7es$

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rhon=hi =lears >ith =ough% Good air ,o<e,ent% Nor,al ta=tile fre,itus DAllergi= Rhinitis$ A=ute 4ron=hitisE% No 7ruits noted% 'I: A=ti<e 7o>el sounds$ a7do,en soft$ nontender$ and nondistended% %ymph: No palpa7le1tender l",ph nodes% ndocrine: No goiter or ,asses noted% Assessment 4ased on her s",pto,s and ph"si=al assess,ent$ >e ha<e ruled out PNA 7e=ause she has not had fe<er$ she does not appear septi= or ill$ and 7e=ause her sputu, =olor =hanges to =lear as the da" progresses% 2e also ruled out !&F 7e=ause her lungs >ere =lear and <itals >ere nor,al% She had no peripheral ede,a and her peripheral pulses >ere not hea<ing or thread"% Signs and s",pto,s of !&F >ere dis=ussed and eAplained to the patient% Gi<en that her ,other has !&F$ >e felt it >as i,portant to edu=ate the patient a7out this =ondition and that her s",pto,s >ere not leading the =lini=an to>ards !&F% 2e ha<e also ruled out Ps"=hogeni= !ough at this point due to her ph"si=al findings% &o>e<er$ 7ased on her presentation$ >e are leaning hea<il" to>ards A=ute 4ron=hitis$ due to the des=ription and a,ount of sputu, produ=ed% Also$ she did state she had ,ild d"spnea >ith a,7ulation% 2e still =ould not rule out Allergi= Rhinitis and GERD% 2hile >e did re<ie> her ,edi=ations$ e<en though she said she had Flonase$ 2e >onder if she a=tuall" uses it on a dail" 7asis% Also >e noted she is =urrentl" ta5es ,edi=ation for her GERD$ 7ut again the in=reased stress ,a" e<o5e the =ough due to a=id produ=tion% At this point$ >e dis=ussed our diagnosti= testing >ith the patient and ordered a !+R so that >e =ould e<aluate her lungs% 2e also eAplained that la7 >or5 >as not >arranted at this ti,e% +ifferential +ia&nosis %ist: ,- Acute .ronchitis: A==ording to &ollier and &ensle" D9:11E$ Infla,,ation of the 7ron=hioles$ 7ron=hi$ and tra=hea$ usuall" follo>s an upper respirator" infe=tions or eAposure to

DIFFERENTIAL DIAGNOSIS PAPER

a =he,i=al irritantC Dp% .L;E% This follo>ing o7?e=ti<e and su7?e=ti<e highl" supports our ,edi=al diagnosis 7e=ause @rs% R# >as diagnosed >ith an (RI on 1919:19% She states in her ROS that her ,u=us is a7out ni=5el si6e$ thi=5 and >hite in =olor and she noti=ed a 7urning sensation to her =hest shortl" after her =ough 7egan$ the 7urning is still present% (pon PE$ there >ere audi7le =ra=5les and rhon=hi that =leared >ith =ough% A =ough that a==o,panies a=ute 7ron=hitis lingers for ,ore than 8 >ee5s due to 7ron=hial h"per rea=ti<it" DDunph" et al$ 9:11E% Duration less than ; ,onths$ >inter ,onths$ (RI for ;'H da"s$ loose ha=5ing =ough that 7e=o,es produ=ti<e$ afe7rile DDains$ 4au,ann$ M S=hei7el$ 9:19E% /- Aller&ic rhinitis: Allergi= rhinitis is infla,,ation of the nasal passage and ,u=ous ,e,7ranes% Nasal =ongestion1ede,a$ snee6ing and =lear rhinorrhea =an a==o,pan" allergi= rhinitis% 2hen the patient is eAposed to an irritant or en<iron,ental su7stan=e$ it triggers an IgE response% This ,ediated response =auses the release of ,ast =ells$ hista,ines$ lue5otrines and prostaglandins% The 7od" rea=ts to these ,ediators and the patient =an eAperien=e an" or all of the a7o<e s",pto,s D&ollier and &ensle"$ 9:11E% Post nasal drip$ antihista,ines and1or de=ongestants are re=o,,ended DDunph" et al$ 9:11E% 0' R+: Thought to 7e =aused 7" sti,ulation of the distal esophagus$ ,a" 7e due to ,i=ro' aspiration% Patients >ith GERD usuall" respond to a =ourse of anti'refluA therap"$ >hi=h usuall" in=ludes anta=ids$ hista,ine 9're=eptor 7lo=5ers$ and proton pu,p inhi7itors DDunph" et al$ 9:11E% A==ording to Dains$ 4au,ann$ M S=hei7el D9:19E$ =ough is >orse at night and =reates a sour taste in ,outh% @rs% R# is =urrentl" pres=ri7ed Prilose=$ Fa,otidine$ and Tu,s for ,aintenan=e therap"% &er =ough has 7een present for a7out ; ,onthsF this is =onsidered a =hroni= =ough% Dunph" D9:11E$ states BA =hroni= =ough is defined as one that lasts longer than ; >ee5sC Dp% ;;1E% So,e assess,ent findings for GERD in=lude: a =hroni= =ough$ =hest pain$ fatigue and sore throat &ollier and &ensle"$ D9:11E% @rs% R# has eAperien=ed all of the s",pto,s

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listed a7o<e$ eA=ept sore throat% &o>e<er$ she did state in her histor" that throat lo6enges resol<e her =ough% 1- AC 2Inhi3itor Induced cou&h: =ough o==urs in a7out 1:K of patients >ho ta5e A!E inhi7itors DDunph" et al$ 9:11E% A==ording to Dains$ 4au,ann$ M S=hei7el D9:19E$ the =ough 7egins hours to ,onths after starting ,edi=ation and the =ough is des=ri7ed as nonprodu=ti<e$ dr" ha=5ing =ough >ith a s=rat=h" sensation in the throat% 4- Pneumonia: A==ording to Dains$ 4au,ann$ M S=hei7el D9:19E$ nois" =ough$ d"spnea$ pleuriti= =hest pain$ sputu, produ=tion$ along >ith ph"si=al findings of ta=h"=ardia$ fe<er$ ta=h"pnea$ inspirator" =ra=5les$ anterior =er<i=al l",ph nodes$ <o=al fre,itus$ and per=ussion dull or flat o<er area of =onsolidation% +ifferential +ia&nosis "a3le: +ia&nosis , Acute .ronchitis Su7?e=ti<e Data Duration N ; ,onths (RI for ;'H da"s &a=5ing =ough that 7e=o,es produ=ti<e Afe7rile DDains$ 4au,ann$ M S=hei7el$ 9:19E +ia&nosis / Aller&ic rhinitis: Snee6ing !ough +ia&nosis 0 ' R+ !ough >orse at night Sour taste in ,outh &istor" of esophagitis !igarette s,o5er Al=ohol A7use O<er>eight DDains$ 4au,ann$ M S=hei7el$ 9:19E O7?e=ti<e Data !oarse fine =ra=5les on aus=ultation Lo>'grade fe<er or afe7rile DDains$ 4au,ann$ M S=hei7el$ 9:19E Allergi= shiners Allergi= salute Rhinorrhea =lear and >ater" DDains$ 4au,ann$ M Nor,al =hest eAa, Nor,al upper respirator" tra=t eAa, Possi7le epigasri= pain >ith palpation or nor,al eAa,

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1: DDains$ 4au,ann$ M S=hei7el$ 9:19E

S=hei7el$ 9:19E !on?u=ti<al in?e=tion @outh 7reathing Palpa7le l",ph nodes Enlarged tonsils and adenoids D&ollier M &ensle"$ 9:11E La7orator"1 Diagnosti= Data !+R !onsider PPD Sputu, =ulture !4! D&ollier M &ensle"$ 9:19E !+R Allerg" testing DDains$ 4au,ann$ M S=hei7el$ 9:19E !4!: eosinophilia if a=ute !onsider =ultures if infe=tion is suspe=ted Sinus fil,s$ !T s=an D&ollier M &ensle"$ 9:11E

&istor" alone D8:K sensiti<it"E% Esophageal p& ,onitoring if patient fails to respond to H >ee5s of e,piri= therap" DDunph" et al$ 9:11E 4lood =ount for ane,ia !+R for aspiration Endos=op" if no response to therap" DDains$ 4au,ann$ M S=hei7el$ 9:19E

Plan @rs% R#3s plan of =are is 7ased on s",pto,s$ ph"si=al findings$ and =onfir,ation of her !+R$ >hi=h re<eals her lungs >ere negati<e for effusions or infiltrates$ ho>e<er$ >as positi<e for peri7ron=hial =uffing hilar region suggesti<e of 7ron=hitis% &er pri,ar" diagnosis is A=ute 4ron=hitis% Se=ondar" diagnosis in=ludes Allergi= Rhinitis and GERD 7e=ause her =ough a=tuall" 7egan in O=to7er >hen =edar =ounts >ere on the rise$ and she has also 7een re=entl" eAposed to in=reased stress$ due to her ,other3s hospitali6ations% &o>e<er$ if treat,ent fails$ >e >ill =onsider dis=ontinuing her Lisinopril DA!E'I =oughE% Generall" >ith an A!E'I indu=ed

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11

=ough$ the =ough appears >ithin the first fe> >ee5s of 7eginning the therap" although ,a" appear >ithin a fe> ,onths DDunph" et al$ 9:11E% Patient edu=ation and =ounseling in=ludes therapeuti=s inter<entions of rest$ in=reasing fluid inta5e to ;'HL1da"$ and using a hu,idifier at night to loosen se=retions DDunph" et al$ 9:11E% Sin=e her !+R did re<eal 7ron=hitis and she >as pre<iousl" treated for an (RI$ >e are pres=ri7ing DoA"=line 1::,g po 4ID for 1: da"s D@=Aule"$ 9:1;E% The patient is en=ouraged to =o,plete the entire =ourse of anti7ioti=s unless she de<eloped hi<es$ rash$ or other ne> s",pto,s of rea=tion to the anti7ioti=% She is instru=ted to =all and notif" the =lini=ian if she has an" -uestions or =o,pli=ations >ith the ne> ,edi=ation% 2e ha<e also added O"rte= 1: ,g po dail" in a, to treat the Allergi= Rhinitis and =hanged Prilose= to 9:,g po 4ID for in=reased =o<erage for GERD s",pto,s% Patient is a>are that in=reased stress produ=es ,ore sto,a=h a=id and the a=id produ=tion =ould 7e an aggra<ating her =ough% Patient <er7ali6es understanding of rationale for in=reasing =urrent dose of Pre<a=id and O"rte=% Additionall" >e refilled Tessalon Pearls 1:: ,g ta7lets$ 1'9 ta7lets TID for her =ough 7e=ause the" did pro<ide her >ith so,e relief% 2e also rene>ed !restor 1:,g po dail"$ @etoprolol ER .:,g 4ID$ Lisinopril 1:,g po dail" in a, 7e=ause she has ne> health=are insuran=e =o<erage% @rs% R# is a>are that her neAt >ell >o,en eAa, D22EE is due @ar=h 9:1;$ she >ishes ,a5e her 22E upon =he=5ing out at the front des5% The patient further agrees that if her s",pto,s do not i,pro<e or if the" >orsen$ she is to return to the offi=e for further e<aluation% 2e do not feel that her =ondition >arrants a =onsult and1or referral at this <isit% Conclusion As 7eginning =lini=ians$ espe=iall" sin=e >e 7oth still pra=ti=e in a=ute =are$ the =hallenge 7e=o,es =hanging our fo=us to pri,ar" =are and understanding the pro=ess of ,anaging =are to

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19

,aintain health or e<en th>art an a=ute eAa=er7ation of =hroni= illness% Further$ >e reali6e that it is i,portant to drill do>n in the anal"sis of s",pto,s$ >hi=h =an pro<ide distin=ti<e <ariations of presentation re-uired for deter,ining the ,ost li5el" differential diagnosis% 2hile the =hest radiograph did suggest 7ron=hitis$ had it not$ understanding the progression of the =ough and if it3s =hara=teristi=s had =hanged sin=e O=to7er >as a =riti=al pie=e of infor,ation =onsidering the patient is ta5ing an A!E'I% Additionall"$ anti7ioti=s >ere pres=ri7ed e<en though the" are not re=o,,ended 7e=ause the offending organis, is generall" <iral D&ollier M &ensle"$ 9:11E% !he clinician did "uestion if the antibiotic was warranted. !he preceptor e$plained it was a mild antibiotic used for bronchitis and would perhaps prevent a secondary bacterial infection. Although edu=ation >as pro<ided on follo>ing up if s",pto,s did not i,pro<e$ re<ie>ing the standards @rs% R# should ha<e returned to the offi=e in se<en da"s for e<aluation and if her s",pto,s persisted for four >ee5s she should ha<e 7een referred to a pul,onologist D&ollier M &ensle"$ 9:11E% Our edu=ation should ha<e in=luded aspe=ts of health pro,otion in=luding >eight redu=tion and a<oidan=e of =affeine% The patient does regularl" present for =ardio<as=ular ,anage,ent for h"pertension e<er" siA ,onths and annuall" for her 22E% &o>e<er$ >e also re=ogni6e that she3s is eAperien=ing a great deal of stress and felt that these >ould 7e 7etter to address the, in @ar=h >hen she returns%

DIFFERENTIAL DIAGNOSIS PAPER

1;

Referen=es Dains$ #%$ 4au,ann$ L%$ M S=hei7el$ P% D9:19E% dvanced health assessment and clinical diagnosis in primary care %&th ed.'. @issouri: Else<ier% Dunph"$ L% @%$ 2inland'4ro>n$ #% E%$ Porter$ 4% O%$ M Tho,as$ D% #% DEds%E% D9:11E% (rimary care the art and science of advanced practice nursing %)rd ed.'. Philadelphia: F%A% Da<is% &ollier$ A% and &ensle"$ R% D9:11E Clinical *uidelines in (rimary Care a Reference and Review +ook. Ad<an=ed Pra=ti=e Edu=ation Asso=iates$ In=% Lafa"ette$ LA @=Aule"$ D% D9:1;E% 4ron=hitis: A=ute 7a=terial eAa=er7ation% Retrie<ed on Fe7ruar" /$ 9:1; fro, http:11>>>%glo7alrph%=o,1anti7ioti=17ron=hitis%ht,%