A patient, K.O., is a 52 years old female, who complains about progressive fever, shortness of breath, fatigue, and cough that has been worsening over the past week. Moreover, she has a history of mild chronic obstructive pulmonary disease.
History of Present Illness
The patient states that a dry cough combined with fatigue started over the past week. K.O indicates the progressive increase in the cough rate, which finally resulted in production of green sputum. A week earlier, prior to developing cough-like symptoms, she recalls having a cold-like symptoms. After the uncommon experience of significant shortness of breath with minor exertion, the woman decided to visit the clinic for a checkup and possible treatment. The patient affirms that sputum production has progressively increased over the recent week. She also reports mild fever shortly thereafter with signs of being fatigued. Patient believes that her chronic obstructive pulmonary disease is mild as compared to previous episodes. She points out that during coughs, she experiences increased heartbeats, which are usually accompanied by shortness of breath. The patient denies chest pain, but states that there is some chest tightness. She has no history of diabetes, heart disease, or lung infections. The patient is using albuterol MDI PRN, HCTZ 25 milligram, and simvastatin 20 milligrams daily.
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The patient is the first born in the family of five children. Both her parents are deceased, and the father died from pneumonia at the age of 72 years. The mother died from breast cancer at the age of sixty-nine. The patient’s paternal and maternal grandparents are deceased. On the side of her paternity, grandfather died of chronic obstructive pulmonary disease at the age of 83. The grandmother died at 70 years because of pelvic cancer. On the maternal side, the grandfather died of heart attack at the age of sixty, while her grandmother perished from pneumonia at the age seventy-four. All the siblings of the patient are alive. One of the brothers, who is now fifty years old, was diagnosed with hyperlipidemia and hypertension.
The patient quitted smoking six years ago because of physician’s advice. Then, she was diagnosed with mild chronic obstructive pulmonary disorder, and smoking was considered as the risk factor that contributed to her condition. She denies consuming alcohol currently, though she used to it, when she was young, about 24 years old. The patient’s husband died five years ago from lung cancer and she has never considered getting married again or finding another company to her lonely life. The patient has two daughters and a son aged 30, 28, and 24 years, who live in the nearby town and visits her regularly.
Review of Systems
Constitutional: The patient denies weight changes, loss of appetite, lower back pains, and improper mental functionalities. She accepts shortness of breath and fatigue, mild fever, and increased heartbeat when coughing.
Eyes: The patient denies pain, pressure, cataract, or other changes in vision.
Cardiovascular: The patient denies paroxysmal nocturnal dyspnea or recent orthopnea. She experiences increased heart beats doing cough. There is no edema, palpitation, or pain reported or identified during examination.
Ear, Throat, Nose: The patient states that she has no issues related to her ears, throat, and nose. She can hear perfectly, no nasal inflammations are observed, and the throat mucosa is pink.
Respiratory: The patient experienced chest pain in the lower lobes of the lungs, feels shortness of breath, which worsens by exertion, produces a green sputum on coughs, has a history of mild chronic obstructive pulmonary disorder, was used to smoking several years ago. She feels chest tightness.
Genitourinary: The patient denies nocturia, dysuria, or hematuria.
Gastrointestinal: The patient denies hematochezia, diarrhea, recent nausea, or abnormal bowel sounds. She has no constipation, melena, or dysphagia.
Skeletal/Muscular: The patient denies painful muscles, swollen abdomen, or joint pains.
Integument: The patient denies itchy skin, jaundice, or pruritis.
Hematology/Lymphatic: The patient denies anemia, hemorrhage, or pain in the lymphatic nodes. Swollen lymph nodes are not identified during examination.
Endocrine: The patient denies polyuria, polydipsia, heat or cold intolerances, diabetes, hair and skin changes, or hypothyroidism.
Neurological: The patient denies numbness or seizures, but reports fatigue. She does not experience any problems while walking or talking.
Psychiatric: The patient denies stress episodes, except death of her husband. She does not suffer from depressive symptoms or panic attacks.
Physical Assessments: Patient’s temperature recorded upon arrival was 101.5F, blood pressure was equal to 126/84 mm Hg, pulse rate was 104 beats per minute, oxygen saturation was 81%. Patient’ weight was 192 lbs, and height was 5 feet 6 inches, which indicates a body mass index (BMI) of 29.6.
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Constitutional: Patient appears tachypneic even under the state of rest.
Head, Eye, Ear, Nose, and Throat: Oral mucosa is dry and without lesions, while oropharynx is slightly erythematous. Nasal lining is clear and moist, no bleeding wasnoticed. Head is normocephalic, maxillary sinuses do not show any signs of tenderness. Tympanic membranes are pearly gray with a good cone of light that extends bilaterally.
Lungs: Mild expiratory wheezes are identified during examination. Crackles are auscultated posteriorly at the base of the lungs. Lung parenchyma shows emphysematous changes, which are typical for mild hyperextension. There is suspicion of minimal pleural effusion.
Chest: The patient’s chest is even and normal during inspiration and expiration.
Cardiovascular: Radial and diastolic pulses are bilaterally equal. It takes less than two seconds for capillary refill. Lower extremity edema, gallops, or murmurs are not identified.
Abdomen: Active bowel sounds are registered, there are no organs with increased size, bruits, or pulsatile masses.
Extremities: No tenderness or edema is registered in distal extremities. Good range of motion is exuded in all articulations.
Skin: There are no signs of paleness in the arms or fingers, skin is warm, smooth, and dry. Lesions, rashes, or cyanosis are not identified.
Neurological: The patient is alert and awake, responds to stimuli.
Genitourinary: Genitals have normal appearance, there are no signs of discharges, swelling, or bad odors. The patient is not suffering from sexually transmitted infections, has normal bladder, cervix, and urethra.
Symptoms identified in the patient suggest several alternative diagnoses: pneumonia, pulmonary embolism, congestive heart failure, acute exacerbation of chronic bronchitis, and chronic obstructive pulmonary disorder. Among them, pneumonia is identified as the patient’s condition based on more accurate analysis. Haemophilus influenzae is the potential causative agent of this disease, as it is frequently detected in outpatients and is less common in the hospitalized ones (Pletz, 2016). It is often identified in patients with chronic obstructive pulmonary disease, who are at the high risk of developing community-acquired pneumonia. These microorganisms consolidate in the air sacs of the lungs (Eccles, Pincus, Higgins & Woodhead, 2014). Their agglomerates can be identified by chest X-rays tests performed, eliminating pulmonary infarction or edema as possible diagnoses. Urinary antigen testing should be performed to support X-ray findings and to offer targeted treatments (National Clinical Guideline Center, 2014). Community-acquired pneumonia is a condition, which is associated with chest tightness and shortness of breath. These problems are reported in patient’s subjective and objective data, therefore validating pneumonia as a correct diagnosis.
Shortness of breath observed in the patient supports pulmonary embolism, however, the woman was not exposed to such risk factors as inactivity or hypercoagulability. Examination shows that there is no evidence for deep venous thrombosis and symptoms progression over the past one week. Thus, pulmonary embolism cannot be supported as a diagnosis, which would explain the observed symptoms (Ho & Smouse, 2015).
Congestive Heart Failure
Congestive heart failure is supported by cardiovascular risk factors identified in the patient, fatigue, shortness of breath, and coughs. However, consolidation identified on the X-ray image supports the occurrence of pulmonary processes. Examination reveals lack of lower extremity edema, right hypochondrial pain, abdominal distention or jugular vein distention that would be observed in case of heart failure (Inamdar & Inamdar, 2016). The infectious nature of the patient’s condition is supported by fever, which would not be observed in case of heart failure. Adventitial breath sounds in case of this disease are usually bilateral, while in the woman’s case they are unilateral. Thus, congestive heart failure cannot be the correct diagnosis
Acute Exacerbation of Chronic Bronchitis
Fatigue, shortness of breath, headache, sputum production, and wheezing are the main common symptoms observed during acute exacerbation of chronic bronchitis (Terrie, 2014). To validate this condition, chest X-ray should be performed and it should have shown a diffused pattern of interstitial infiltrate instead of a consolidated one. Moreover, wheezing would have been bilateral in case acute chronic bronchitis. As highlighted by Pletz (2016), ‘atypical organisms’, such as Mycoplasma pneumonia, are the most common causative agents of chronic bronchitis. However, Haemophilus influenzae is suspected according to the observed symptoms, which indicates that acute exacerbation of chronic bronchitis is not a correct diagnosis.
Chronic Obstructive Pulmonary Disease
The possibility of chronic obstructive pulmonary disease is supported by shortness of breath experienced by the patient. However, she was prescribed albuterol MDI PRN, which was expected to clear air passages. At the same time, the drug had minimum effect on the patient because of the pneumonic infection. The patient stopped smoking six years ago, while this habit is an immediate risk factor for chronic obstructive pulmonary disease (Overington et. al., 2014). Thus, it is unlikely that the condition developed now in spite of the fact that the risk factor has been avoided recently. In addition, negative spirometry results indicate that the patient’s diagnosis is different from chronic obstructive pulmonary disease.
Treatment: Hydrochlorothiazide 25 milligrams daily should be continued to manage the increased heart rate. The patient should be prescribed Simvastatin 20 milligram daily to address hyperlipidemia. To treat pneumonia, the patient should receive intramuscular injection of ceftriaxone in 1-2 g q12-24h IV/IM doses for 10 days. The duration of treatment may vary with respect to efficiency of individual recovery. If this medication appears effective within a week, it could be stopped within seven days.
Diagnostic Testing: Spirometry, X-ray, urinary antigen testing.
Problem-Oriented Education: The patient should be informed about side effects of medication and the ways to manage them. The woman should visit the clinic immediately, when a problem is noted. Health care practitioner should educate the patient to avoid double pills intake if she misses the previous dose. Sharing of medication is not allowed and the patient should be informed about it.
Health Promotion/Maintenance Needs: The patient should be explained the need in general exercising and stimulated to perform it. The woman should drink much water for rehydration, as well as be encouraged to eat lots of fruits and vegetables.
Cultural & Lifespan Considerations: Heath care professional should remember about ethnic diversity and related variation in communication styles and norms. Enough time should be allocated for the patient during visits. Gossips around the patient should be discouraged.
Referrals: The patient should be referred to major hospitals, if the applied treatment does not result in positive changes.
Follow up: The patient’s health status should be checked every three weeks during return to clinic sessions.