Pulmonology Case Study

HPI

A65-year-oldCaucasianfemalepresentswithachiefcomplaintofcoughfortwoweeks. Shehasbeencomplainingofdrycoughsinthepasttwoweeksandlowgradefever thatstartedtwodays ago andwasashighas101per oral.Shehashadadecreased appetitebutnonauseaand vomiting. The coughoccursduringthenightandsheneeds to situpinachairtobeabletobreathe easier. Thecoughismainlydry,rarely productive.

Shehadbeenprescribedinhalersinthepast;theyhavebeenhelpfulbutshedoesnot usethemonaroutinebasis.Shehasbeenprescribedantibioticsinthepastaswelland thatseemstohelpwhensheisacutelyill.Shehasbeensufferingfromshortness of breath forthepasttwoweeksfollowinganykindofactivitymainlybecauseofthedrycough.Shethinksit’spossiblethatthere’ssomeproblemwithher“heart.”Sheisalso complainingofslightsore throat especiallyinthemorningandfeelsshemayhavelung cancer.

Thepatient’ssymptomshavebeenworseningoverthepasttwodays.

Shehashadsimilarepisodesinthepast.Thelastwasthreemonths agowhenshehad to gototheemergencyroomandtheytoldherthatsheneededtobehospitalized.She declinedhospitalizationatthattimeandwastreatedandreleased.Shesaystheygave herantibioticsandaninhalerbeforedischargingher.Shementionedthatthoughittook some timetofeelbetter,therewasgradualimprovementinherconditionfollowingthat treatment.Accordingtoher,thisistheworstepisodethatshecanremember.She’svery concernedtodaythatshecouldhavepneumoniaandmightrequirehospitalization.

Sheisseekingmedicalattentiontodaybecauseofthefeverandprolongednatureofher illness.

PMH

Thoughshehasbeentreatedforthisprobleminthepastwithantibioticsandinhalers, shehasnotbeenhospitalized.Thepatienthadachestinvestigationthelasttimeshe hadthisproblem.Shestatesthatshedidnothavepneumoniabutdidhave“emphysema.”Thehealthcareprofessionalswantedtodopulmonaryfunctiontests,but shedeclined.

X-rayreport:

X-rayresults:HyperinflationofbothlungswithanincreasedAPdiameter.Thereis evidenceofemphysema.      .

She statesthatshehadasthmaasachildandisacigarettesmoker.Shealsohadahysterectomywaybackin1970s.Besidesthese,shehasnoknownchronicmedical problems.

ROS

Shortnessofbreathwithactivity.Nodiaphoresis.Shehashadafever.No nausea and vomiting.Denieschestpressuresensationwithphysicalactivity.Nopalpitations.

MEDICATIONS

Thepatientdoesnottakeanyprescriptionmedicines.Shetakesoccasionalover-the- counterTylenolforpain.

Tylenol650mg,2POas needed.

ALLERGIES/ REACTIONS

Sheisallergicto sulfur drugsthatcausea rash.

SOCIALHISTORY

Thepatienthasbeenwidowedfor20years.Sheisreceivinganannualpensionof

$40,000.00andhassomemoneythatshehassavedinthebank.Shehasahighschool diplomaandownsher house. Though shehaslittledisposableincome,herfinancesare essentiallystable.Shehaslittleknowledgeofcommunityresourcesthatareather disposal.

Shehasa primarycareprovider,whomsheseesthreetofourtimeseveryyearfor a physical examination. The physicianisverybusyanddoesnotspendmuchtimewith her.Shehasinsurancebutitdoesnotcoverallherprescriptionmedications.Sherelies alot onsamples.

Shehastwogrown-updaughterswholiveinthenearbycommunity.Theyareboth in their fortiesandarealiveandwell.Thepatientwouldlikeherdaughterstobemore involvedinherlife,butsheisnotsurehowtoapproachthemaboutthis.The patient’s perception ofself-efficacyhasbeendecliningoverthepasttenyears.Shefeelsthat she could befeelingdepressed because shedoesnotgetoutofthehouseveryoftenand this depressionisonlygettingworsewitheachpassingyear.

Thepatienthasverylowlevelofday-to-day stress. However,sherealizesthather depressivesymptomsmaybecausingsomeofherphysicalsymptoms.

Shegoestochurchandhassomecontactsthere.Sheseesherdaughtersonce a month.Thesepeoplearehersupportsystem,butshehasnoonetotalktoonaroutine basis.

HABITS

•    Diethabits

Shehasa healthydietandherdietaryintakeisadequate.Thepatienthas positive health beliefsandknowsthatsheshouldbedoingmoretomaintainahealthylifestyle. Shedoesnotgetadequateexercisebecauseofhershortnessofbreath.Sheenjoys visitingherphysician.

Smoking:Shehassmokedonepackperdayfor40years. Alcohol:Shedeniesalcoholuse

SubstanceUse:Shedeniesanystreetdruguse

 WORKHABITS

Shehasalwaysbeenahairdresser;isretirednow.Shegoestochurchandoccasionally attendssomeoftheirfunctions.Herhobbiesincludesewing.SheisfromtheUnited Statesandlivesinasub-urbansetting.Crimerateinherlocalityislowwitheasyaccesstopublictransportation.Thereareavarietyofcommunitygroups,butsheisnotaware of these resources.

FAMILYHISTORY

Hertwooldersistersarealiveandwell,onewithosteoporosisandonewithbreast cancer. Her75-year-oldsisterwasdiagnosedwithosteoporosisattheageof55.Her72- year-oldsisterwasdiagnosedwithbreastcancerat60yearsofage.

PHYSICALEXAMINATION

VitalSigns:BP:130/72leftarmsittingregularcuff;

T:101po;P:100andregular;R:20, non-labored;Wt:130#;Ht:55”.

HEENT:Whitematerialonthebuccalmucosa;doesnotwipeoffwithtongueblade. Lymph Nodes:None

Lungs:Decreasedbreathsounds,dulltopercussionrightlowerlobe.Endexpiratory wheezeinrightlowerlobe.Noralesorrhonchi.Increasedanterior-posteriordiameterto chestwall.

Heart: RRR without murmur

 Carotids:Nobruits Abdomen:Benign