2nd Most likely DX:Myocarditis

Rationale for the Diagnosis and explanation:
-Recent group setting and possible viral or bacterial exposure
Fever, fatigue, and chest pain
-Long term use of corticosteroids weakening immune system
-Shallow breathing, tachypnea, from thoracic contusions
-Tachycardia, possibly the heart trying to compensate for decreased cardiac output
-Peripheral Edema suggests possible increased hydrostatic pressure due to the left side of the heart not functioning properly due to decreased diastolic pressure from inflammation
-dypnea on exertion.

● Etiology & Risk Factors: most common identified cause is infection. Patient spends time around other community residents, recent visit with granddaughters and recent boating event could have introduced virus, bacteria, etc. Exposure to lake water could also contain parasite, bacteria, etc. (Al-Akchar et al., 2023)

● Signs & Symptoms: chest pain, fatigue, tachycardia, arrythmia, signs of infection: fever, diarrhea, body aches, shortness of breath, headache, swelling in legs (Gilotra, n.d.)

● Briefly explain the condition / pathophysiologic process (150 words or fewer): virus/bacteria enters myocardial cells initiating inflammatory process and immune response, cell damage causes release of interleukin and DAMPs which mediate inflammatory cells, spleen replenishes pro-inflammatory cells that travel to the damaged myocardium, interferon-gamma is released causing more pro-inflammatory recruitment. This results in chronic inflammation, cardiac enlargement and cardiac dysfunction (Al-Akchar et al., 2023)

● How does the patient “Fit” that description disease? Pertinent Positives: potential exposure to virus, chest pain, tachycardia, signs of infection-fever, diarrhea, body aches, dyspnea, headache, lower extremity edema, leukocytosis Pertinent Negatives:: no abnormal heart sounds, chest discomfort arises with cough

▪ How does the pathology of the condition crossover to other body systems or impact the body as a whole (example: inflammatory meditators)

● Management of the diagnosis and rationale (Assuming this diagnosis is correct) Again be specific and tie it back to the patho, how will these management strategies impact the patient/ pathophysiologic condition or WHY are they appropriate?

Cooper L., (2022). Clinical manifestations and diagnosis of myocarditis in adults. Uptodate. Retrieved on october 21, 2023 from https://www.uptodate.com/contents/clinical-manif estations-and-diagnosis-of-myocarditis-in-adults?search=acute%20myocarditis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H391781590

1st Most like DX: Aspiration Pneumonia

● Briefly explain the condition / pathophysiologic process:
Pneumonia is an infection of the alveoli caused by inability to remove pathogens from the lungs leading to activation of the inflammatory system which attracts inflammatory factors, cytokines to the infection site. The alveoli fill up with fluid and pus making air exchange difficult. The presence of pus in the parenchyma leads to decreased lung compliance, dyspnea, hypoxia, tachypnea (DynaMed, 2023)

● How does the patient “Fit” that description disease? Pertinent Positives & Negatives
Patient presents with positive symptoms of dyspnea, diminished breath sounds, shallow breathing, thick yellow green sputum, pale, diaphoretic, drowsy, confused, tachycardic, crackling sounds on one side, diminished breath sounds, elevated white blood cells count, clammy skin, fatigue
Negative symptoms include no retractions, no tracheal deviation

● Rationale for the Diagnosis
● Explanation about why this diagnosis is on your list of potential conditions for this patient. In other words what elements of the case led you to this? Be sure to consider all factors: patient may have been exposed to infectious pathogen from granddaughters or boating event or from Walmart as the germs tend to spread from person to person when someone infected coughs or sneezes, germs can be breathed into lungs. If the immune system is unable to destroy the germs, they can eventually develop into pneumonia. The patient may have inhaled a bacterium in the water from near drowning as some bacteria associated with pneumonia have been found in dirty water. Also the patient may have experienced pulmonary insult due to submersion, thus can lead to pneumonia, in addition to his history of smoking (DynaMed, 2023)

● Etiology & Risk Factors
● Are there any underlying / compounding factors that play a role with this disease (ex: history of smoking would support a lung cancer diagnosis)
Respiratory viruses and streptococcus pneumoniae are the most common cause of community acquired pneumonia.
Risks factors include age 65 and older, residing in a healthcare setting, cigarette smoking or exposure, alcohol abuse, poor oral hygiene, other infections such as HIV, acid reducing drugs, inhaled corticosteroids, antipsychotics, and diabetes medications (Epocrates, n.d.).
Other risks factors include chronic comorbidities such as diabetes mellitus, chronic lung disease (COPD, bronchitis, asthma), kidney disease, hepatic disease, heart disease and opioids use (Dynamed, 2023)

● Signs & Symptoms:
Patients with community acquired pneumonia typically present with fever, cough, productive cough, shortness of air, difficulty breathing, chest pain, presence of leukocytes, imaging revealing lung infiltrate, with elderly patients showing non-typical symptoms such as confusion, malaise, diarrhea, and myalgia (DynaMed, 2023).

● What unknown pieces of information do you need /want to know and WHY.
A chest X-ray showing some inflammation or consolidation will help confirm the diagnosis. Also, the sputum test result to find out the causative pathogen (Epocrates, n.d.).
● What findings would confirm this diagnosis? Be specific with values & findings:
Patient's white blood cell count is elevated which implies the immune system is fighting some sort of infection. Crackles were present during auscultation. dullness on percussion

● Management of the diagnosis and rationale (Assuming this diagnosis is correct) Again be specific and tie it back to the patho, how will these management strategies impact the patient/ pathophysiologic condition or WHY are they appropriate?

Procedures:

Zebra DX: Bronchiectasis

● Pathophysiologic process: Bronchiectasis is a dilation and eventual destruction of bronchioles with impaired conduction of air from accumulated mucous/inflammatory products/bacterial products/fibrosis/remodeling of the bronchioles. It is typically described as a vicious cycle or circle, or even a vortex of infection-inflammation-blockage-destruction-infection (colonization)-destruction-inflammation. Neutrophils, neutrophil-derived proteases, cytokines, interleukins, macrophages, Cd+ cells, all play a role in the inflammation and destruction. Bronchioles lose elastin, change shape, fibrose, and at the most severe stage- destroy muscle and cartilage.The predominant bacteria Pseudomonas aeruginosa and Haemophilus influenzae, mycobacteria, viruses, and fungi occupy the miasma inside the mucus-filled and damaged bronchioles, recruit more neutrophils which exhibit poor phagocytosis capability. (Bush, A., & Floto, RA. 2019; Amati F et al. 2019)

● Pertinent Positives: cough/sputum/dyspnea/malaise/loss of smell & appetite & Negatives: weight gain/bruising/lack of pleuritic chest pain

● What unknown pieces of information do you need /want to know and WHY: His childhood history of infections/possible asthma, and whether he has had multiple bought of respiratory infections: this would fit the pattern of risk and exacerbations.
● What findings would confirm this diagnosis: A high resolution CT of the chest showing a bronchoarterial ratio in which the airway lumen is at least 1.5 or more in diameter than its adjacent blood vessel and a pattern of an enlarged rather than tapered distal bronchial tree (Barker, A. 2023,a).

● Management of the diagnosis and rationale (Assuming this diagnosis is correct) Again be specific and tie it back to the patho, how will these management strategies impact the patient/ pathophysiologic condition or WHY are they appropriate?

Medications

● Rationale for the Diagnosis:
Bronchiectasis may be brought on by a single episode of severe pneumonia (Patient has multiple risk factors and signs and symptoms of pneumonia such as exposure to his grand-daughters/boating event guests, presumed aspiration of lake water; F, cough, dyspnea, crackles, elevated CRP, among other signs) (Barker, A. 2023). Risk factors for bronchiectasis which the patient has include 1.childhood respiratory infections (he may have had several as he recalls having hives when taking penicillin); 2. asthma (he may have had asthma as a child as his mother had it) and 3. obstruction of the airway from cardiac abnormalities (the patient may have an enlarged heart due to his numerous cardiovascular risk factors of HTN, OSA, obesity, unhealthy diet, smoking, alcohol.)(Barker, A. 2023,a)

● Etiology & Risk Factors
The main risk factor in this case is the lake water that apparently entered the patient's lungs due to the boating accident. This is the aspiration which could be the initial insult to the lungs causing the inflammation and dilation of the bronchioles.Aspiration in adults is often associated with altered consciousness. The patient had loss of memory with the boating accident (Barker, A. 2023,a).

● Signs & Symptoms: Cough, sputum, dyspnea, rhinosinusitis, pleurisy, crackles, decreased sense of smell, dullness on percussion (Barker, A. 2023,a; Amati F et al. 2019)

Bush, A., & Floto, RA. (2019). Pathophysiology, causes and genetics of paediatric and adult bronchiectasis. Respirology. 24: 1053–1062. https://doi.org/10.1111/resp.13509
Amati F., Simonetta E., Gramegna A., Tarsia P., Contarini M., Blasi F., & Aliberti S. (2019). The biology of pulmonary exacerbations in bronchiectasis. Eur Respir Rev. 28(154):190055. doi: 10.1183/16000617.0055-2019. PMID: 31748420; PMCID: PMC9488527.
Barker, A. (2023). Clinical manifestations and diagnosis of bronchiectasis in adults. UpToDate. Retrieved October 20th 2023 from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-bronchiectasis-in-adults?search=bronchiectasis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5990869 a

3rd most likely DX: Post-Traumatic Hemothorax with Empyema

● Briefly explain the condition / pathophysiologic process: Hemothorax is the presence of blood in the pleural space as a consequence of blunt or penetrating trauma to the chest leading to abnormalities in ventilation and oxygenation that cause dyspnea (Legome, 2023). Development of Empyema is a long term complication of untreated hemothorax with pneumonia (Legome, 2023).

● How does the patient “Fit” that description disease? Positives and Negatives

Rationale for the Diagnosis

● What unknown pieces of information do you need /want to know and WHY

Unknown information:
Onset of symptoms - how long has this been untreated/undiagnosed
Cause of ecchymosis to thoracic area - did patient sustain blunt force trauma to chest and what was the mechanism of action - help identify organ involvement
Pain - does he have pain at the ecchymosis site which may indicate rib or organ involvement.
Any known bleeding disorders - patient may be at risk for bleeding

● What findings would confirm this diagnosis? Be specific with values & findings

XRAY: upright chest xray that shows 300ML or greater of blood is diagnostic of hemothorax. Xray may also show presence of pneumonia; a common complication of untreated hemothorax; which may in turn lead to empyema. (Legome, 2023).
US: Recommended in patients with normal chest xray that present with marked chest tenderness, hypoxia, dyspnea, tachypnea. Allows for detailed evaluation of the intrathoracic structures and presence of fluid in pleural space (Legome, 2023).

● Management of the diagnosis and rationale (Assuming this diagnosis is correct) Again be specific and tie it back to the patho, how will these management strategies impact the patient/ pathophysiologic condition or WHY are they appropriate?

Tube thoracostomy for drainage of purulent empyema fluid; in place until drainage less than 50 mL in 24 hours or lung re-expansion seen on chest XR (Iguina & Danckers, 2023)

References: Legome, E., MD (2023, September 20). Initial evaluation and management of blunt thoracic trauma in adults. UpToDate. Retrieved October 20, 2023, from https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-thoracic-trauma-in-adults?source=bookmarks_widget

Gomez, L. P., & Tran, V. H. (2023, August 8). Hemothorax. National Library of Medicine. Retrieved October 20, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK538219/