Question

33-year-old white woman arrives at emergency room. Her doctor diagnosed acute bronchitis and treated her with bronchodilators, antibiotics and short-acting oral steroids. This management did not improve symptoms. She indicates that she has gradually worsened, and has lost weight. Denies exposure to outdoor activities, has had no contact with sick people, and she has not traveled in recent months.

The review of systems is negative for, night sweats, palpitations, chest pain, neurological changes, muscle changes, or bruising, or bleeding. She reports having a dry cough, shortness of breath mainly when exercising. The medical record was inadvertently printed and placed on the counter.
Social history: smoker for the past 10 years, one pack daily; However, she quit smoking shortly before the onset of symptoms, six months ago. She denies alcohol and drug use.
Illicit. Married, has a monogamous relationship and has three children aged 15 months to 5 years, works in A bakery, has two pigeons as pets. The student insisted on asking about the
alcohol consumption. In addition, she discussed the case with other medical students.
Medical History: There are no known food allergies or environmental allergies. No history past physician, Hx.surgical past cholecystectomy. Medications: Lisinopryl 50mg /daily, S/V: T, 102 F; P 128/min; R, 26/min; B/P 130/86Physical examination: Performed in the presence of a medical student, but there is no evidence of
Patient consent. General: anxious, with shortness of breath that causes it to stop
in the middle of a sentence. Respiratory: has diffuse rales, wheezing; tachypneic
Cardiovascular: tachycardia with regular sinus, without murmurs, or gallops. Gastrointestinal:
nausea, vomiting, diarrhea, abdominal pain, bowel sounds present, no murmur, no mass
palpable. Laboratories: PLT 74,000 per mm3; HGB, 8.3 g positive sputum culture for
Histoplasmosis, WBC 10,000 Chest XRay: Interstitial Pneumonitis

a) Mention and analyze at least four alterations of the physical examination and history related to the
diagnosis.

b) Indicate four essential aspects contained in HIPAA.

Answer 1

The patient's symptoms like dry cough, shortness of breath, rales, wheezing, tachypnea, and weight loss, coupled with her positive sputum culture for Histoplasmosis, support the diagnosis of interstitial pneumonitis. Essential HIPAA aspects include the Privacy, Security, Breach Notification, and Enforcement Rules.

Step-by-step explanation:

Analysis of Physical Examination and History

The case of the 33-year-old woman presents several alterations in her physical examination and history that are pertinent to her diagnosis:

• Dry cough and shortness of breath, mainly with exertion, are classic symptoms of lower respiratory tract infections or interstitial lung diseases.
• Weight loss can sometimes indicate a chronic systemic condition; it is particularly concerning in this context.
• Diffuse rales and wheezing on lung auscultation indicate significant abnormal airway or interstitial processes.
• Tachypnea and tachycardia (increased respiratory and heart rates) consistent with compensatory responses to hypoxemia.

The diagnosis is further supported by the laboratory finding of positive sputum culture for Histoplasmosis and a Chest XRay showing Interstitial Pneumonitis, which fits with her respiratory symptoms.

Essential Aspects of HIPAA

HIPAA ensures patient privacy and the security of health information. Four essential aspects are:

• Privacy Rule: Protects the privacy of individually identifiable health information.
• Security Rule: Sets national standards for the security of electronic protected health information.
• Breach Notification Rule: Requires covered entities to notify affected individuals following a breach of unsecured protected health information.
• Enforcement Rule: Provides standards for the enforcement of HIPAA rules, including penalties for violations.