Historical and Physical Examination
Patient Name: Mr. William O’Connor
Date of Admission: 12/01/2019
Acute chief complaint: Cough
Subjective Data
Identifying data:
William O’Connor is a 42-year old male, married, operational manager, who was born in the United States.
Chief Complaint (CC)
“ I’m short of breath and I cannot stop coughing.”
History of Present Illness (HPI)
The patient is a 42-year-old male that was admitted to the emergency department complaining of shortness of breath for the past several days. His problems began four days ago when he got a cold. His cold consisted of a sore throat since his job forced him to work in cold and damp air. At first, he simply felt tired but later developed a shortness of breath. Initially, his cough was dry but after 24 hours of coughing, he produced abundant and yellow sputum. He did not think a lot about the cough because he continually coughed during the winter of every year. According to a report of his wife, he coughs and spits up every time he gets out of bed. He has since been exhausted from coughing. He has been weak and fatigued and has not been able to do any house chores such as grocery shopping or laundry.
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Acute Chief Compliant (CC)
He appears tired, haggard, and anxious and speaks with difficulty due to his condition.
OLDCART Acronym
Onset: 4 days ago.
Location: Mostly on the chest and throat.
Duration: He coughs every day which lasts 4 to 5 minutes and at various times during the night. He has to cough for some time every day he gets out of bed.
C haracteristics : Mr. O’Connor has shortness of breath to the extent that he could hardly speak. He complains that he has pain at the left side of his chest whenever he coughs. He becomes tired during a coughing spell or when performing simple activities.
Aggravating factors : The pain becomes worse in the morning or during the night
Relieving factors: The pain quiets if he sits still, takes some painkillers, or takes a cup of hot tea.
Treatments: The patient has been using cough drops, tea, and hot lemon. He has taken ibuprofen to ease with the pain.
Past Medical History
O’Connor has been treated in the past for pneumonia, infections of his legs, and blood pressures. He was treated for similar episodes of coughing and shortness of breath in the past two years. The episode took place on 23/03/2017. Just the previous year on 15/01/2018, he was hospitalized because of problems with his pancreas and smoking too much. He smokes about five cigarettes on a weekly basis.
Past Surgical History
Mr. O’Connor has never undergone any form of surgery. He is up to date with all of his immunizations and received a tetanus booster the previous year. He has not had the influenza vaccine required for the current season. He underwent an eye exam over the last five months and his last dental exam was carried out in the past three months.
Family History (FH):
Mr. O’Connor reports a family history of lung cancer and chronic bronchitis. His father complained of coughs, chest pains and was diagnosed with lung cancer. The cancer was acute at the time of diagnosis and he died a few months after diagnosis. Mr. O’Connor noted that some of his relatives have been diagnosed with various respiratory problems.
Social History (SH):
Mr. O’Connor lives with his wife and together have two children. He drinks alcohol rarely, takes mostly wine and does not have any history of alcohol abuse. He smokes at least 1 pack of cigarettes on a weekly basis. He does not do illegal drugs and has never tried them. He works as an operational officer in an automotive manufacturing company. He has been working with the company for more than ten years. He has been working with the company for approximately seven years. The nature of work is difficult and he has to work in a place that is damp and dusty.
Medications, OTC, supplements
Mr. O’Connor has been taking Ibuprofen for the past few weeks in order to ease the pain. His dosage increased in the last 4 days when his pain became severe.
Allergies (medications, food, other) and reaction
Mr. O’Connor reports that when he takes penicillin he gets a rush. He denies any latex or food allergies. However, exposure to cats and dust causes him to have a running nose, to get itchy and swollen eyes and symptoms of asthma.
Review of Systems (ROS)
The patient states that he had a stuffy nose, excessive coughing with thick sputum which had lasted for more than a month. The coughing became severe within the past few days. The patient denies to the feeling of nausea, vomiting, diarrhea, and states that he had lost some weight due to the condition. The patient notes that his skin becomes blue whenever his coughing increases.
Explanatory Model
Background: He stopped going to work a few days ago when the situation became severe.
Affect: He feels exhausted about the situation which gets worse with the pain.
Troubles: He is worried that this may be more than a simple cough virus and could be cancer.
Handling: The adequate support he receives from his wife.
Empathy: The patient agreed that he was in a very difficult situation and that he was going through a lot.
Objective Data
Vital signs:
Blood pressure is 145/82 mmHg. The heart rate is 96/minute and is regular. The respiratory rate is 28/minute. He had a temperature of 101 o F.
General Survey:
He appears to be much older than his stated age of 42 years. He looks tired, anxious, and haggard. He shows severe and acute signs of distress. He speaks with much difficulty and quickly becomes breathless. He finds it difficult to perform any activity and quickly gets tired after walking a few meters. There is cyanosis that intensifies when his coughing increases and during his coughing spells.
Physical Exam:
An examination of the head and neck shows that there is the use of the accessory muscles throughout respiration. His jugular veins become dilated to 5 cm with a wave.
An examination of the chest shows that he uses accessory respiratory muscles with the anterior-posterior diameter of the chest increased. The respiration rate is high, respiration is regular and becomes longer in expiration. The fremitus is decreased and the lungs fields are diffused with percussion. Coarse crackles, expiratory wheezes, and rhonchi can be heard bilaterally. Most of the sounds become clear with coughing.
An examination of his cardiovascular system reveals soft heart sounds and no murmur is detected.
The liver edge is round, the abdomen is round and soft and bowel sounds are not heard.
Possible diagnosis
Mr. O’Connor shows most of the signs and symptoms that are usually associated with chronic bronchitis. Some of the symptoms such as having difficulty in breathing and showing signs of respiratory compromise seen through the use of accessory muscles of the neck.
Diagnostic study
A physical examination was carried out on the on his lungs, adventitious sounds were heard like that of wheezes and loud rhonchi. Analysis of the x-ray showed that the lungs were enlarged, there were irregular air packets and a flattened diaphragm. Rhonchi were heard through rumbling sounds that resembled snoring due to the obstruction of airways with secretions while wheezing were heard through continuous sounds and high sounds caused by vibration in narrow airways. These abnormal sounds are common for people that have chronic bronchitis (Sarkar, 2015). Another physical finding was the clubbing of his fingers due to the lack of oxygen in his blood which indicates chronic bronchitis. The examination of the x-ray did not show chronic bronchitis but the enlarged lungs were a symptom for the infection (Washko, 2010).
References
Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015). Auscultation of the respiratory system. Annals of thoracic medicine , 10 (3), 158-68.
Washko G. R. (2010). Diagnostic imaging in COPD. Seminars in respiratory and critical care medicine , 31 (3), 276-85.
