Patient to stop to catch his breath even

Patient Initials: XY  
                     Age: 60 years                        Gender:
Male

SUBJECTIVE DATA

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Chief Complaint: cough and difficulty in breathing for
one month

History of Presenting
Illness (HPI): Patient
XY is a 60 year-old male who presented with a one month history of cough and
difficulty in breathing for similar duration of time. He reports that he began
coughing first, which produced copious amounts of sputum. He denies any bloody streaks
or abnormal color of the sputum. He reports that the cough becomes worse with
activity but denies associated chest pains.

He
also started having difficulties breathing with accompanying breathlessness about
a day after the cough. He reports that it is worse with activity and is
slightly relieved by rest. He reports that he has been forced to relocate to a
nearer place of work since he cannot walk as fast as before in the same
distance. 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 denies
night sweats and fever but reports that he has lost some weight over last
couple of weeks and feels easily fatigued. He denies having limb swellings,
palpitations, orthopnea and dizziness. He denies any pressure feelings within
the chest and any history of asthma as a child. He also reports that his
symptoms have been worsening with time. He reported that he had experienced
similar symptoms at least once over the last two years.

Current medications: 
he is a known hypertensive patient currently on:

·        
Metoprolol
10 mg per oral daily

·        
Furoseminde
40mg per oral daily

Other
that the anti-hypertensives he takes no other medication

Past Medical History:  he
denies having had any surgeries or blood transfusion.  He reports to having been admitted to hospital
and treated for pneumonia in 2014. He was diagnosed with hypertension in 2010
and is compliant on medication.

Allergies: he denies having any allergies

Family History: his parents are both dead; father died
aged 70 years of heart attack, mother at 55 year following a road traffic
accident. He has three sons all of whom are alive and healthy. He reports to
have 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 heart
disease.

Social history: he reports to have smoked at least one
pack of cigarettes and drank alcohol; for the past 30 years. He however reports
that since he was diagnosed with hypertension he has tried to cut down on that
habit but he has not fully stopped.

He
worked at a fabric making factory for 15 years before he retired 5 years ago
and is receiving his pension currently. He lives alone in a one-bedroomed
apartment with good ventilation and reports that his sons often visit him.

Review of Systems:

            Cardiovascular System: see HPI

            Respiratory
System: see HPI

            Gastro-Intestinal
System: Denies any nausea, vomiting, abdominal pains, diarrhea or Constipation

            Genito-Urinary
System: denies any flank pains, denies change in micturition frequency,
color or consistency, and denies urethral discharge or difficulty initiating
micturition.

            Musculoskeletal
System: denies any joint, muscle or limb pains.

            Neurological
System: 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.

Would
also check for jaundice, pallor, lymphadenopathy and cyanosis

Vital Signs: Would take the patient’s Blood Pressure,
Pulse rate, respiratory rate and temperature.

Respiratory System
Examination:

            Observation: for
chest wall structural abnormalities (might impair breathing e.g. Scoliosis and
Kyphosis), chest wall movements with breathing, use of accessory muscles for
breathing (indicates respiratory distress, Medscape) and scars

            Palpation:
for structural abnormalities, tenderness, chest wall excursion (to
determine level of chest expansion during breathing) and tracheal position.

            Percussion:
percuss over the lung surface both anteriorly and the back on one side
while comparing to the opposite side. Dull to percussion can indicate
consolidation as in pneumonia, stony dull could be due to pleural effusion or
could be hyper-resonant in pneumothorax. (davidson)

            Auscultation: Auscultate
over the lung surface on the chest and back one side at a time and comparing to
the opposite side. Normal lung tissue has vesicular sounds while bronchial
sounds could mean fibrosis, consolidation or effusion. Crackles could also be
due to effusion. (ref)

Cardiovascular System
Examination:

            Observation:
Same as in respiratory exam. In addition, check for hyperactive precordium
(indicative of cardiac pathology), median sternotomy marks (indicative of
cardiac surgery).

Palpation:
palpate the apex beat
and its radiation. (Could be displaced in cardiomyopathy), check for murmurs and
other abnormal heart sounds (ventricular

hypertrophy, mitral stenosis etc.), check
for parasternal heaves (indicative of right ventricular hypertrophy)

Auscultation:
for apex beat, murmurs
and other heart sounds and possible radiations, count the pulse rate and
characterize the pulse.

Other Examination: Limb palpation for temperature and edema

ASSESSMENT
Differential Diagnoses:

Bronchitis
(RI): part of the
spectrum of Chronic Obstructive Pulmonary Disease (COPD) due to chronic
inflammation of the airways. It is characterized by progressively worsening
cough and difficulty breathing with sputum production. Tobacco smoking is
associated with its development.

Emphysema
(RI): Also part of
the COPD spectrum with similar characteristics as Bronchitis. Usually, the
airspaces are permanently enlarged with accompanying destruction of alveolar
walls. Reduction in lung compliance increases the work of breathing thus increasingly
worsening work of breathing. Chronic tobacco use is a risk factor for the development
of the disease.

Asthma
(RI/RO): chronic
inflammation of the airways due to hypersensitivity to common allergens. Usually
presents with cough, difficulty breathing and wheezing that worsens if not
managed appropriately.

Tuberculosis,
TB (RI/RO):is an infection
of the lung parenchyma by bacterium; mycobacterium tuberculosis and thus causing
inflammation. Presents with chronic cough with sputum production, weight loss,
fever and night sweats. Positive history of TB contact can help rule in
infection.

Congestive
Heart Failure (RI/RO): Heart
failure because the heart cannot generate adequate force to pump blood. Usually
causes back-pooling of fluid in the lungs causing cough and progressively worsening
difficulty in breathing and edema.

Pleural
effusion (RI/RO): Fluid
in the pleural cavity causing cough and difficulty in breathing. Can be
exudative (due to infection such as TB) or transudate (as a result of raised pulmonary
pressures causing fluid to sip into the pleural space).

PLAN

Diagnostic Tests

Pulse
Oximetry: to
determine the level of oxygen saturation in the blood and thus diagnose
ventilation perfusion mismatch as can occur in COPD.

Sputum
Analysis: for
culture and microscopy to identify infectious organism (TB), fungal lung
infections such as Aspergillums and enable institution of proper treatment.

Plain
Chest X-RAY:  enables visualizations of lung tissue
pathology. Pleural effusions, cavitation, chest wall structural anomalies,
cardiac hypertrophy can all be identified on chest radiograph.

Chest
CT-Scan: Can help
visualize pathologies that are not likely to be seen with plain X-Rays such as
Fibrosis as occurs in Bronchiectasis.

Echocardiograph:
rule out cardiac
anomalies as the cause of cough and difficulty breathing. Most cardiac disease
such as Congestive heart failure or valvular diseases can present with
respiratory symptoms.