Patient Initials: XY Age: 60 years Gender:MaleSUBJECTIVE DATAChief Complaint: cough and difficulty in breathing forone monthHistory of PresentingIllness (HPI): PatientXY is a 60 year-old male who presented with a one month history of cough anddifficulty in breathing for similar duration of time. He reports that he begancoughing first, which produced copious amounts of sputum. He denies any bloody streaksor abnormal color of the sputum. He reports that the cough becomes worse withactivity but denies associated chest pains.
Healso started having difficulties breathing with accompanying breathlessness abouta day after the cough. He reports that it is worse with activity and isslightly relieved by rest. He reports that he has been forced to relocate to anearer place of work since he cannot walk as fast as before in the samedistance. At times he has to stop to catch his breath even while slow walking.He denies any contact with a person who has a chronic cough; he also deniesnight sweats and fever but reports that he has lost some weight over lastcouple of weeks and feels easily fatigued. He denies having limb swellings,palpitations, orthopnea and dizziness. He denies any pressure feelings withinthe chest and any history of asthma as a child.
He also reports that hissymptoms have been worsening with time. He reported that he had experiencedsimilar symptoms at least once over the last two years.Current medications: he is a known hypertensive patient currently on:· Metoprolol10 mg per oral daily· Furoseminde40mg per oral dailyOtherthat the anti-hypertensives he takes no other medicationPast Medical History: hedenies having had any surgeries or blood transfusion. He reports to having been admitted to hospitaland treated for pneumonia in 2014. He was diagnosed with hypertension in 2010and is compliant on medication.
Allergies: he denies having any allergies Family History: his parents are both dead; father diedaged 70 years of heart attack, mother at 55 year following a road trafficaccident. He has three sons all of whom are alive and healthy. He reports tohave one sibling aged 57 years who is healthy. Apart from his father and him,he reports that no other member of his family has had chronic illness such as Hypertension, Asthma, Diabetes or heartdisease.
Social history: he reports to have smoked at least onepack of cigarettes and drank alcohol; for the past 30 years. He however reportsthat since he was diagnosed with hypertension he has tried to cut down on thathabit be he has not fully stopped.Heworked at a fabric making factory for 15 years before he retired 5 years agoand is receiving his pension currently.
He lives alone in a one-bedroomedapartment with good ventilation and reports that his sons often visit him.Review of Systems: Cardiovascular System: see HPI RespiratorySystem: see HPI Gastro-IntestinalSystem: Denies any nausea, vomiting, abdominal pains, diarrhea or Constipation Genito-UrinarySystem: denies any flank pains, denies change in micturition frequency,color or consistency, and denies urethral discharge or difficulty initiatingmicturition. MusculoskeletalSystem: denies any joint, muscle or limb pains. NeurologicalSystem: Denies changes in vision, headaches or any convulsions.OBJECTIVE:General Examination: Would observe his general appearance;nutritional status, level of enthusiasm, signs or respiratory distress,movement characteristics in terms of how fast or how strong are his movements.Wouldalso check for jaundice, pallor, lymphadenopathy and cyanosisVital Signs: Would take the patient’s Blood Pressure,Pulse rate, respiratory rate and temperature.
Respiratory SystemExamination: Observation: forchest wall structural abnormalities (might impair breathing e.g. Scoliosis andKyphosis), chest wall movements with breathing, use of accessory muscles forbreathing (indicates respiratory distress, Medscape) and scars Palpation:for structural abnormalities, tenderness, chest wall excursion (todetermine level of chest expansion during breathing) and tracheal position. Percussion:percuss over the lung surface both anteriorly and the back on one sidewhile comparing to the opposite side. Dull to percussion can indicateconsolidation as in pneumonia, stony dull could be due to pleural effusion orcould be hyper-resonant in pneumothorax.
(davidson) Auscultation: Auscultateover the lung surface on the chest and back one side at a time and comparing tothe opposite side. Normal lung tissue has vesicular sounds while bronchialsounds could mean fibrosis, consolidation or effusion. Crackles could also bedue to effusion. (ref)Cardiovascular SystemExamination: Observation:Same as in respiratory exam. In addition, check for hyperactive precordium(indicative of cardiac pathology), median sternotomy marks (indicative ofcardiac surgery).Palpation:palpate the apex beatand its radiation. (Could be displaced in cardiomyopathy), check for murmurs andother abnormal heart sounds (ventricular hypertrophy, mitral stenosis etc.
), checkfor parasternal heaves (indicative of right ventricular hypertrophy)Auscultation:for apex beat, murmursand other heart sounds and possible radiations, count the pulse rate andcharacterize the pulse.Other Examination: Limb palpation for temperature and edemaASSESSMENTDifferential Diagnoses: Bronchitis(RI): part of thespectrum of Chronic Obstructive Pulmonary Disease (COPD) due to chronicinflammation of the airways. It is characterized by progressively worseningcough and difficulty breathing with sputum production. Tobacco smoking is arisk factor for its development. Emphysema(RI): Also part ofthe COPD spectrum with similar characteristics as Bronchitis. There ispermanent enlargement of airspaces with destruction of alveolar walls.
Reduction in lung compliance increases the work of breathing thus progressiveworsening difficulty of breathing. Chronic tobacco smoking is a risk factor forthe development of the disease.Asthma(RI/RO): chronicinflammation of the airways due to hypersensitivity to common allergens. Usuallypresents with cough, difficulty breathing and wheezing that can worsen withoutproper management.Tuberculosis(RI/RO): infectionof the lung parenchyma by mycobacterium tuberculosis causing inflammation. Presentswith chronic cough with sputum production, weight loss, fever and night sweats.
Positive history of TB contact can help rule in infection.CongestiveHeart Failure (RI/RO): Heartfailure because the heart cannot generate adequate force to pump blood. Usuallycauses back-pooling of fluid in the lungs causing cough and progressively worseningdifficulty in breathing and edema.Pleuraleffusion (RI/RO): Fluidin the pleural cavity causing cough and difficulty in breathing. Can beexudative (due to infection such as TB) or transudate (due to raised pulmonarypressures causing fluid sippage).PLANDiagnostic TestsPulseOximetry: todetermine the level of oxygen saturation in the blood and thus diagnoseventilation perfusion mismatch as can occur in COPD.
SputumAnalysis: forculture and microscopy to identify infectious organism (TB), fungal lunginfections such as Aspergillums and enable institution of proper treatment.PlainChest X-RAY: enables visualizations of lung tissuepathology. Pleural effusions, cavitation, chest wall structural anomalies,cardiac hypertrophy can all be identified on chest radiograph.ChestCT-Scan: Can helpvisualize pathologies that are not likely to be seen with plain X-Rays such asFibrosis as occurs in Bronchiectasis.Echocardiograph:rule out cardiacanomalies as the cause of cough and difficulty breathing. Most cardiac diseasesuch as Congestive heart failure or valvular diseases can present withrespiratory symptoms.