Patient Initials: __JH_____ Age: __60_____ Gender: ____M___
Chief Complaint: Case #3 “I have a cough that’s getting worse.” (Laureate Education, 2012).
HPI: Mr. Hendricks is a 60 year-year old Caucasian male who presents today complaining of a cough that is progressively getting worse; more frequent over the past three days. He states that his cough is accompanied by expectoration of thick green secretions accompanied by some blood at times. He has associated symptoms of shortness of breath that is aggravated when walking and nothing seems to help. Patient also states that he had difficulty trying to fall asleep last night because he felt like he was getting a fever and had intermittent chills and sweats and took Tylenol. He states “I have never felt like this before and would like to know what’s going.”
Medications: over the counter Tylenol 650mg po at nights.
Allergies: No known drug or food allergies. No seasonal allergies.
Past Medical History: No medical history provided.
Past Surgical History: No surgical history provided.
Immunization history: Up to date with immunizations. Influenza shot received September 2018. Pneumococcal vaccine received October 2018.
Personal/Social History: Patient denies smoking, drinks wine socially, exercise with brisk walking three times weekly and tries to eat a balanced diet. He has a master’s degree in finance and works as an accountant at an accounting firm. He is a safe driver who drives to work daily and always wears seatbelt. He lives with his wife who is a homemaker who helps baby sit twin granddaughters. Patient denies history of recent travel to foreign country within the three months.
Review of Systems
General: productive cough with green phlegm and blood at times; shortness of breath, chills, night sweats, fever and restlessness.
HEENT: Patient denies head or nasal congestion, headache, nasal discharge, dizziness, vertigo. Patient states productive cough with green-colored sometimes bloody phlegm.
Cardiovascular: Patient denies palpations. Has some chest tightness.
Respiratory: Patient states that he has SOB that worsens with walking. Has productive cough with green-colored sputum and occasional hemoptysis. Patient states that he hears whistling noises when he breathes.
General: Mr. Hendricks is a 60 year old Caucasian male and a good historian who is relatively healthy and has good hygiene. Alert and oriented x 3, looks age appropriate with normal facial expression and appropriate behavior. He coughed a few times during exam and appears to be in some respiratory distress with shortness of breath.
Vital signs: Ht. 5’9”, Wt. 210 lbs; BMI= 30, blood pressure 128/70, pulse of 82, respirations of 20 and labored, temperature of 100.9 and O2 saturation on room air of 89%.
HEENT: No headache or head masses. No lesions. Wears glasses. Pupils equal and reactive to light; ears symmetrical, no tenderness or discharge. No frontal or maxillary sinus tenderness. No discharge from nose and mucosa pink and moist. Wears partial upper dentures. Throat appears red. Good hygiene.
Neck: No masses, full range of motion. Thyroid size normal.
Integumentary: Warm and most
Respiratory: Thorax symmetrical with diminished breath sounds. B/L rales and expiratory wheezes throughout. Wet productive cough.
Cardiovascular: regular heart rate with good S1 and S2 heart sounds. No S3, S4 or murmur.
Gastrointestinal: abdomen protuberant. Normoactive bowel sounds in all four quadrants.
Peripheral vascular: No peripheral edema. 2+ dorsalis pedis pulses palpated bilaterally.
Lab Tests and Results:
- CBC: Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection (Mayo Clinic, 2018.)
- Sputum culture: is taken after a deep cough and analyzed to help pinpoint the cause of the infection (Mayo Clinic, 2018).
- O2 saturation: decreased oxygen saturation indications indicates hypoxemia. Normal range should be 95-100% on RA (Mayo Clinic. 2018).
- Chest X-ray: helps your doctor diagnose pneumonia and determine the extent and location of the infection (Mayo Clinic, 2018).
- Bacterial pneumonia: is an infection of the air sacs in one or both lungs which may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing, dullness to percussion, decreased breath sound, fatigue. It is most commonly caused by Streptococcus pneumoniae(Mayo Clinic, 2018). Since the patient appears to have most of these symptoms, this is a great possibility.
- Acute bronchitis: Acute bronchitis, often called a “chest cold,” is the most common type of bronchitis. It occurs when the airways of the lungs swell and produce mucus which makes one cough. It is caused by a virus and often occurs after an upper respiratory infection. Symptoms include sore throat, soreness in the chest, fever, coughing with or without mucus production, fatigue, mild headaches and watery eyes (CDC, 2017b). This can also be a possibility based on the patient’s symptoms.
- Asthma exacerbation: Asthma is a disease that affects your lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing. Asthma can be controlled by taking medicine and avoiding the triggers that can cause an attack (CDC, 2017a). This can also be a possibility based on the patient’s symptoms.
- Bronchiectasis exacerbation: Bronchiectasis is a condition in which the airways (called bronchial tubes) that branch from the trachea into each lung become widened and inflamed. Such damage limits the ability of the airways to clear bacteria and mucus from the lungs, resulting in sputum production, cough, and shortness of breath. Bronchiectasis can be congenital or acquired as a result of an infection. Symptoms include cough, shortness of breath, wheezing, weight loss, fatigue and chronic sinusitis (Mount Sinai, 2018). Based on these symptoms, this can be a possibility for patient diagnosis.
- COPD exacerbation: chronic obstructive pulmonary disease (COPD) experiences long-term and progressive damage to their lungs. This affects air flow to the lungs. Symptoms include rapid shallow breathing, increasing amounts of mucus, which is often yellow, green, tan, or even blood-tinged, experiencing shortness of breath at rest or with minimal activity, such as walking from one room to another and wheezing more than usual (Healthline.com, 2018). Based on patient symptoms, this can also be a possibility for the patient condition.