Case 3B: Herb
1. After presenting his symptoms, it is important to ask the patient several follow-up questions in order to arrive at a possible diagnosis, which will later be confirmed by several laboratory tests. At this point, it is wise to ask the patient to give details about his occupational background and the places that he has been to prior to the onset of the symptoms. It is also necessary to check what time of the day does coughing usually occur and what does he usually do to make the cough get better. The same is true with fever, ask the patient to give a recap of the usual time of the day when temperature of the fever is highest and if it is consistent or if it is recurrent; also, it is also important to note the fever medications that he used (if any). Also, ask for the consistency of the sputum and the amount of phlegm that accompanies the coughing.
Afterwards, kindly request the patient to describe, in his own words, the characteristic of pain and the location where he usually experiences any discomfort and for how long does the usual paining lasts. For his shortness or difficulty of breathing (SOB or DOB), do an inquiry on the rate of incidence that DOB or SOB occurs and what are his immediate responses every time this happens.
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2. In this case, Herb must be having an infection, as manifested by an increase in his WBC. Laboratory results for his Arterial Blood Gases (ABGs) showed a normal PaO2 value, with a slightly elevated pH, and low value for PaCO2. The values for pH is 7.56 (normal: 7.35-7.45)1 and PaO2 is 26 (normal: 35-45)2, these values are indicative that Herb may be experiencing respiratory alkalosis, a condition where the CO2 levels in the blood drop below the normal range and is primarily caused by hyperventilation.3 This condition can be diagnosed by a simple blood test to test the pH of blood and tests on ABGs.4 But these tests alone could not make the diagnosis entirely conclusive, other tests have to be done to arrive at a final diagnosis. For instance, an HCO3 test should be done to verify the patient’s respiration status and to finalize the diagnosis as respiratory alkalosis.
3. It could be suggested that he take antibiotics since there is indication of an infection. Other medications may be required to treat fever and nausea.5 It is also important to assess the environmental factors, especially those that could be possibly present in his house, which could further implicate the patient’s respiratory rate. It is highly advisable to avoid staying in a place where there is a possibility of inhaling second-hand smoke. Checking the condition of the ventilation and a close examination for the presence of gas fumes is of great significance in the patient’s recovery.
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