Patient Information: Mr. Walter (Wally) Hendricks, 62-year-old Caucasian male
Subjective
CC: shortness of breath accompanied by a cough
HPI: The cough that began as a throat tickle escalated, resulting in breathing difficulty and feels as if it comes from the lungs. The cough began a week ago, and he hardly coughs secretions, however, when he does blood is at times accompanied, and the secretion is thick green. The cough rates rise to about 7/10 in severity.
Current Medications:
The patient takes Atenolol 50mg and Losartan 50mg for high blood pressure every morning since 1997 and HCTZ 25mg since 2000 for a similar purpose. He has been taking Zocor 10 mg for high cholesterol since 1998 and takes it through the mouth. The patient also takes stroke prevention medication since 1998 ASA 81 mg every evening. Since 2002, the patient was diagnosed with Diabetes type II hence started taking Metformin 500m twice a day. He also takes Ibuprofen 200mg tablets for pain.
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Allergies:
Cough causing Lisinopril and Lipitor.
Patient Medical History:
Recent: Influenza, Tdap, MMR, and Zoster - Shingles.
Past: - chickenpox, pertussis, and pneumonia all at a tender age;
Surgeries - fractured both bones on the left forearm at age 35
Current Medical History - Diabetes type II, Hypercholesterolemia, hypertension, CAD,
Social History:
The patient is a retired accountant married Elizabeth for 40 years with two children. Does not smoke but smokes passively while at poker games, takes beer on Wednesdays and wine.
Family History:
His mother is 85 years and has high blood pressure and was diagnosed with a stroke at age 75 years. His father died at age 80 from coronary artery disease. The father also had BPH, diabetes, and carotid artery disease. On the other hand, his son is healthy while this daughter is asthmatic. He has one sibling who also has high blood pressure.
Review of Systems
Stable weight of 210lbs with fatigue and chills.
HEENT: Eyes: properly functioning, PERRL. Ears, Nose, Throat: No signs of hearing loss, nasal congestion, sneezing, or runny nose.
SKIN: No rash or itching. Is warm and moist.
CARDIOVASCULAR: no signs of discomfort on the chest. The heart rate is also good.
RESPIRATORY: Thorax is symmetrical; lung sounds are auscultated all fields anterior and posterior bilaterally - diminished breath sounds with rales and expiratory wheezes noted throughout; cannot appreciate rhonchi; has a wet, productive cough during the exam. Pulse oximetry noted to be 89% on room air. Does have dyspnea on exertion, denies orthopnea and PND.
Objective
The patient feels no chest pains despite having difficulty breathing. The blood pressure is stable at 128/70 and a strong heart rate of 82 strong. The patient has no nasal discharge but has a flushed check signaling fever. There is also no peripheral edema from the diagnosis. Full neuro exam was not performed, but the patient has normal mentation.
Diagnostic results:
There was a high chance of pneumonia hence necessitating chest x-ray. Lab work: BMET, CBC, sputum culture, and blood cultures x2 performed. Both sputum and blood cultures should be performed in the presence of risk factors (Ball, 2017).
Assessment
Differential Diagnoses
Pneumonia – Research shows most cases of death at old age result from community-acquired pneumonia. Moreover, patient history shows a history of cough, pleuritic pain, and dyspnea. Additionally, the chest radiograph shows an infiltrate just like that present in pneumonia cases. Bronchitis - It is essential to check for bronchitis since they share similar symptoms with pneumonia ( King & Daviskas, 2010).
Upper Respiratory Infection – It is essential to check for this infection despite the fact that patient shows no signs of runny nose, headache, sore throat, and nasal congestion.
Pulmonary Embolism – This is necessary to diagnose despite the patient denying having chest pains but has short breath.
Tuberculosis – there is a high chance considering that the patient was in contact with a person who was coughing. Moreover, tuberculosis bacteria spread through the air ( Lee, & O'Sullivan, 2003).
Plan
In the outpatient setting, there is a lack of evidence on an antibiotic regimen for CAP treatment. Azithromycin and other macrolides are essential in the absence of comorbidities. This follows as most adult CAP cases are attributed by pneumonia and atypical pathogens (Abolmaali, 2004). In the event the patient used antimicrobials in past 3 months and is exhibiting comorbidities like lung, chronic heart, lung, liver, or renal disease; diabetes mellitus; and other immunosuppressing conditions, then the best treatment would be fluoroquinolone. It is recommended 5 days be the minimum treatment period for patients with CAP. Moreover, the patient should be encouraged to consume Tylenol 500-650mg to reduce fever and discomfort ("Tuberculosis: Clinical features and diagnosis," 2013). The patient should also get adequate rest and fluid to reduce dehydration. However, in the event these remedies do not work, and the patient gets worse, it is encouraged to seek medical attention, and it may signal an enhanced level of pneumonia. It is required that the patient stay consistent on medication and consider x-ray.
References
Abolmaali, N. D., Schmitt, J., Krauss, S., Bretz, F., Deimling, M., Jacobi, V., et al. (2004). MR imaging of lung parenchyma at 0.2 T: evaluation of imaging techniques, a comparative study with chest radiography and interobserver analysis. Eur. Radiol. 14, 703–708. doi: 10.1007/s00330-003-2215-y
Ball, L., Vercesi, V., Costantino, F., Chandrapatham, K., and Pelosi, P. (2017). Lung imaging: how to get a better look inside the lung. Ann. Transl. Med. 5:294. doi: 10.21037/atm.2017.07.20
King, P., & Daviskas, E. (2010). Pathogenesis and diagnosis of bronchiectasis. Breathe, 6(4), 342-351. doi: 10.1183/18106838.0604.342
Lee, K., & O'Sullivan, R. (2003). Cardiac sarcoidosis: An elusive diagnosis. Heart, Lung, And Circulation, 12(2), 112. doi: 10.1046/j.1444-2892.2003.00204.x
Tuberculosis: Clinical features and diagnosis. (2013). Clinical Pharmacist. doi: 10.1211/cp.2013.11123346
