Week 6 Main Discussion Post:

Case 3

Patient Name:  J. H.

Age:  68

Gender:  Male

Subjective Data:

Chief Complaint (CC):  “ I don’t feel good.  I’m short of breath and its getting worse.”

History of Present Illness (HPI):

            Mr. Hendrick is a 68-year-old Caucasian male who complains of SOB and fatigue that has increased over past couple days.  He explains his cough is getting worse; he’s tired all the time and is worried he may have lung cancer.  Walking and talking make his SOB worse, and it is impacting his ability to sleep.  He has taken Tylenol for his fever and chills, but “nothing is making it better.”  He complains of a sharp pain to his right upper chest that is present when he coughs, which is accompanied by thick, green, blood-tinged sputum.  He rates the chest pain a 6/10 during a cough; otherwise, he is pain-free. 

Medications:

            Tylenol 1,000 mg as needed   

Allergies:

            No known drug, food, or environmental allergies.

Past Medical History (PMH):

            Varicella as a child

            Scarlet fever as child

Past Surgical History (PSH):

            Vasectomy in 2003

Sexual/Reproductive History: 

            He is heterosexual with one sexual partner.  Denies a history of STIs or problems with his libido.

Personal/Social History:

            Patient has smoked for 30 years and has recently cut back to three cigarettes a day.  No alcohol or illicit drugs use.

Immunization History:

            Up-to-date. T-dap in 2010 and Influenza vaccine received in December 2016.  Has not received the pneumococcal vaccine.

Significant Family History:

            Mother is deceased, age 75, breast cancer.

            Father is deceased, age 82, complications from myocardial infarction.

            He has two adult children that are alive and healthy with no significant medical problems.

Lifestyle:  J. H. has a bachelor’s degree in criminal justice and recently retired from his local police department after 30 years.  He plays golf, walks 3 miles each day, and enjoys eating fruits and vegetables from his garden.  He lives in a retirement community with his wife and attends church every Sunday.

Review of Systems (ROS):

            General:  Positive fatigue, fever, and chills.  Denies any recent weight gain or weight loss.

            HEENT:  Head:  Denies history of head trauma or headaches.  Eyes:  Patient wears eyeglasses; last eye exam was 6 months ago, no vision changes, floaters, excess tearing, or history of eye infections.  Ears:  He denies trauma, tinnitus, or hearing loss. Nose:  Positive congestion, denies drainage, or changes in his sense of smell.  Throat:  Denies a sore throat.  No problems chewing or swallowing food.  His last dental exam was 9 months ago, no issues with dental caries or oral lesions.  

Neck:  Denies pain, swelling, or injury. Full ROM.

            Breasts:  No lumps, drainage, or changes to his breast. 

Respiratory:  Dyspnea with and without excretion that increases when walking and talking.  Persistent, moist, productive cough accompanied with thick, green, blood-tinged sputum.  No history of tuberculosis exposure or screenings.  No recent exposure to anyone with similar symptoms to the patient.

CV:  Positive pain with cough that is localized to right upper anterior chest.  He denies palpitations or swelling of his extremities.

GI:  Denies nausea, vomiting, flank, or abdominal pain.  No constipation, blood, or changes in his bowel habits. 

            GU:  No pain, burning, or difficulty urinating.

            MS:  Denies history of swollen joints, trauma, or limited ROM to his extremities.

            Psych:  No sleep or mood disturbances.  Denies history of depression or anxiety.

            Neuro:  Denies any dizziness or headaches.  No history of seizures or falls.

            Integument/Heme/Lymph:  Denies any itching, lesions, or cuts to the skin.  No bleeding disorders or coagulopathies.  Denies lymphadenopathy.

            Endocrine:  No changes in skin or hair texture.  Denies heat or cold intolerances.   

            Allergic/Immunologic:  No asthma, atopy, or chronic infections.

Objective Data:

            Physical Exam:

            Vital signs:  BP 128/70, right arm, sitting, regular cuff; Pulse 82, regular rhythm; Respirations 20, labored; SAO2 89%, room air; Temperature 100.9, oral; Weight 210 pounds; Height 5’ 7”; BMI 33.

General:  Patient appears well nourished and is dressed appropriately.  Patient maintains leaning forward position, appears anxious, and provides quick responses to questions.  He coughs several times a minute and his SOB increases with communication.  The patient is a reliable historian. 

HEENT:  Head:  Atraumatic, normocephalic with no lesions.  Hair is gray in color, shiny, coarse, and equally distributed. Alopecia noted to the central scalp area.  Eyes:  PERRLA, EOMI, and conjunctiva translucent.  Ears: no foreign bodies or odor to bilateral auricles, both tympanic membranes are intact and pearly gray in color with positive visualization of landmarks (handle of malleolus, umbo, and light reflex).  Nose:  Erythematous nasal mucosa.  No drainage.  No tenderness or pain to frontal or maxillary sinuses with palpation and percussion.  Throat:  No oropharynx exudate.  Posterior pharynx is mildly erythematous, and the uvula is midline. 

Neck:  Supple, non-tender, and the trachea is midline.

Chest/Lungs:  Chest rise and fall is symmetric.  Respirations are shallow; no retractions or accessory muscle use.  Expiratory wheezing and inspiratory rales auscultated to right middle lobe AP&L.  Increased tactile fremitus and dullness noted to right middle lobe with percussion anteriorly and posteriorly.  Resonance to left upper and lower lung fields with percussion and no adventitious breath sounds auscultated AP&L. 

Heart/Peripheral Vascular:  Heart RRR, normal S1 S2, no murmurs.  Bilateral dorsalis pedis pulses +2.  No pedal edema noted.

ABD:  Round, soft, and non-tender.  Bowel sounds x4 quadrants.

Genital/Rectal:  No lesions noted to the external genitalia.  

Musculoskeletal:  Steady gait with full ROM.

Neuro:  A&O x3; CN II-XII grossly intact.  DTR +2 to bilateral extremities.

Skin/Lymph nodes:  Skin is warm and moist, capillary refill less than 3 seconds.  Skin turgor easily recoils no tenting.  No lymphadenopathy.

Key Assessments and Diagnostic Tests:

            1.  Tactile Fremitus and Percussion

            System specific examination techniques and diagnostic testing will assist the practitioner in narrowing down Mr. Hendricks diagnosis.  In addition to auscultating the lung fields, the palpable vibrations felt during tactile fremitus are used to evaluate for the presence of excess air, fluid, solid masses, or lung consolidation (Ball, Dains, Flynn, Solomon, & Stewart, 2015).  Mr. Hendricks physical exam reveals, dullness with percussion, and increase resonance to the right middle lung both anteriorly and posteriorly, which are physical findings consistent with pneumonia (Dains, Baumann, Scheibel, 2016). 

            2.  Complete blood count (CBC)

            Obtaining a CBC may reveal an elevated or low white blood cell count, which would identify if an acute infection (leukocytosis) or possible sepsis (leukopenia) (Gamache, 2016b).  Elevation in an individual’s WBC may also indicate allergic disease (Dains et al., 2016). 

            3.  Sputum Culture

            Blood may be present in an individual’s sputum due to a bacterial infection, a chronic infectious disease, cancer, or tuberculosis (TB) (Ball et al., 2015).  Obtaining a sputum culture from Mr. Hendricks will aid in the identification the type of microorganism causing his infection, which will optimize his plan of care and treatment.  The sputum results would eliminate or verify the presence of acid-fast bacilli, which would be consistent with TB (Dains et al., 2016). 

            4.  Chest Radiography

            Based on Mr. Hendricks history of smoking, dyspnea, cough, and sputum characteristics, obtaining a chest x-ray will help provide answers to whether his condition is due to an acute or chronic lung or cardiac condition.  Results of a chest x-ray can assist in the diagnosis of malignancy, pulmonary edema, pneumonia, pneumothorax, and can evaluate the heart and its blood vessels (Mayo Clinic, 2017).  Mr. Hendricks AP chest radiography shows a blurred right lung border, increased opacity, and consolidation in the right middle lobe.  His chest x-ray is negative for any nodules or masses, which may have suggested possible malignancy.  A positive silhouette sign, opacity, and consolidation to the middle lung area are consistent with lobular pneumonia (University of Virginia, 2013a).  Furthermore, a chest x-ray positive for infiltrates with or without a pleural effusion is a common finding in half of all individuals who smoke or have chronic obstructive lung disease (COPD).  Also, these individuals are commonly infected with H. influenzae (Gamache, 2016a).

            5. QuantiFERON-TB Gold blood test

            If Mr. Hendrick’s chest x-ray findings or his exposure to TB were questionable, ordering a QuantiFERON-TB Gold blood test would be ideal to determine if he has active TB or latent infection (Cash & Glass, 2014).  The results would confirm or rule out TB as a diagnosis.

            6. Electrocardiogram

            Obtaining an electrocardiogram will be helpful to determine whether a patient’s chest pain is musculoskeletal, respiratory, or cardiac in nature.  Mr. Hendrick’s age, smoking history, and family history of cardiovascular disease place him at an increased risk for cardiovascular disease.  An ECG can rule out an acute myocardial infarction and identify abnormalities in the heart’s rhythm that may be causing Mr. Hendrick’s dyspnea and chest pain.  Mr. Hendrick’s ECG results reveal regular sinus rhythm, negative ST depression or elevation, PR interval is less than 0.20, and QRS is 0.10. 

           

Assessment/Plan:

Differential Diagnosis:

            1.  Community-acquired pneumonia

            Pneumonia is caused by a bacteria, fungus, or virus, resulting in an acute onset of constitutional symptoms (fever, chills, and fatigue).  Clinical findings of pneumonia include dullness to areas of consolidation with percussion, and diminished breath sounds with crackles and rhonchi to the lung fields affected (Ball et al., 2015).  Fever, an increased respiratory rate, and the production of sputum are objective findings associated with pneumonia (Ball et al., 2015).  Sputum that is green with small amounts of blood is typically indicative of a bacterial infection (Ball et al., 2015).  Pleuritic chest pain and confusion may accompany pneumonia (Musher &Thorner, 2014).  Mr. Hendrick’s chest pain and sputum characteristics, lung sounds, chest x-ray, percussion, and tactile fremitus findings are congruent with bacterial pneumonia. 

            2.  Acute bronchitis

            Bronchitis is caused by an inflammation in the large airways, which produces a dry cough that is nonproductive, eventually leading to nasal congestion and a productive cough.  Furthermore, fever may or may not be present (Dains et al., 2016).  This condition is more commonly found in individuals who smoke, is typically viral, and presents with upper respiratory infection symptoms (Fenstermacher& Hudson, 2016).  Assessment and diagnostic findings with acute bronchitis include rhonchi with expiration, a slightly increased or normal WBC, and a normal chest x-ray (Dains et al., 2016).  Mr. Hendrick’s history of smoking, productive cough, fever, and lung sounds may suggest he has acute bronchitis.  However, he denies a recent upper respiratory infection, and his chest x-ray is positive for lung consolidation, which suggests a bacterial illness.

            3.  Tuberculosis

             TB produces lung consolidation with or without a pleural effusion, and a patient may have a cough productive with blood-tinged sputum.  However, latent disease may not yield any clinical findings (Ball et al., 2015).  Common symptoms of TB include fever, fatigue, chills, night sweats, productive cough that may be purulent or contain blood, and anterior, posterior, or supraclavicular lymph node lymphadenopathy may be present (Cash & Glass, 2014).  Chest x-ray findings in primary TB may be normal (Cash & Glass, 2014).  However, during reactivation, adenopathy, focal lung consolidation, pleural effusion, or cavitation from fibrosis and nodal calcifications may be visible (University of Virginia, 2013b).  Mr. Hendrick’s sputum and constitutional symptoms are congruent with TB.  However, his physical assessment is negative for lymphadenopathy, and his chest x-ray is negative for fibrosis and nodal calcification. 

            4.  Chronic obstructive pulmonary disease (COPD)

            Individuals who smoke have an increased risk of developing COPD, which is manifested by acute attacks, leading to a worsening of dyspnea.  As a result, there is an increase in pus-like sputum production (Dains et al., 2016).  Individuals with COPD typically have a barrel chest and an increased respiratory rate with distant lung sounds (Dains et al., 2016).  Clinical manifestations of an acute exacerbation may be precipitated by an upper respiratory infection, leading to a fever of unknown origin, wheezing, and cough (Dains et al., 2016).  Hyperexpansion of the lungs is a common finding of COPD on a chest x-ray (Dains et al., 2016).  Mr. Hendrick’s chest x-ray did not show evidence of hyperexpansion.  Also, his sputum (green with blood) and lung sounds (unilateral wheezing and rales) are inconsistent with this diagnosis.

            5.CHF

            An altered level of consciousness, restlessness, accessory muscle use, increased SOB, adventitious lung sounds, cough, and frothy sputum are common symptoms of heart failure (Dains et al., 2016).  Physical examination findings associated with chronic heart failure include peripheral edema, elevated jugular venous pressure, and a displaced apical impulse (Mcmurray et al., 2012).  Electrocardiogram (ECG) results may show LV hypertrophy, an AV block, intraventricular conduction delay, or Q waves (Mcmurray et. al., 2012).  There is a less that 2 percent chance that an individual has heart failure when presenting with signs and symptoms when his or her ECG is unremarkable (Mcmurray et al., 2012).  Although Mr. Hendrick’s has a cough, increased SOB, wheezing and rales, he does not have any additional heart sounds (S3, S4), murmurs, peripheral edema, or a previous history of heart disease that would reinforce acute or chronic heart failure. 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide of physical examination (8^th ed.). St. Louis, MO: Elsevier Mosby.

Cash, J. C., & Glass, C. A. (2014). Family Practice Guidelines (3^rd ed.). New York, NY: Springer Publishing Company.

Dains, J. E., Baumann, L. C., &Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5^th ed.). St. Louis, MO: Elsevier Mosby.

Fenstermacher, K., & Hudson, B. T. (2016). Practice guidelines for family nurse practitioners. St. Louis, MO: Elsevier.

Gamache, J. (2016a). Bacterial pneumonia. Retrieved from http://emedicine.medscape.com/article/300157-overview#showall

Gamache, J. (2016b). Bacterial pneumonia workup. Retrieved from http://emedicine.medscape.com/article/300157-workup?pa=Zs1hwdItMX6LHzZgMg0J%2B6AWZWTnXKDgFshTo9%2FgZ%2FdKQehkVcwy2FP5R6d0BdkmJyGvMX%2Fu%2BWdIXoARf%2FT0zw%3D%3D#showall

Mayo Clinic. (2017). Chest x-rays: Why it’s done. Retrieved from http://www.mayoclinic.org/tests-procedures/chest-x-rays/basics/why-its-done/prc-20013074

Mcmurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A., Bohm, M., Dickstein, K., . . .Ponikowski, P. (2012). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Heart Journal, 33(14), 1787-1847. doi:10.1093/eurheartj/ehs104

Musher, D. M., &Thorner, A. R. (2014).Community-acquired pneumonia. New England Journal of Medicine, 371(17), 1619-1628. doi:10.1056/nejmra1312885

University of Virginia.(2013a). Pneumonia. Retrieved from https://www.med-ed.virginia.edu/courses/rad/cxr/pathology3chest.html

University of Virginia.(2013b). Tuberculosis. Retrieved from https://www.med-ed.virginia.edu/courses/rad/cxr/pathology4chest.html

 

 

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• 1505559403-Week 6 Main Discussion Post.docx