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Patient Initials: Patient H Age: 65 yrs old Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): Patient H reports cough associated with with shortness of breath, and fever, as verbalized, “I do (have cough). And it's getting worsehad chills and sweats and it took forever to get to sleep”
History of Present Illness (HPI): Patient H is a 65 yrs old Caucasian, male who presents self in the outpatient ward with productive cough that was, according to the patient “getting worse”, accompanied by shortness of breath and fever with chills and sweats. He has difficulty bringing up secretions but when able, were characterized of being greenish in color, with streaks of blood at times. Walking was reported to aggravate his shortness of breath but patient H also noted that even when seated and talking he also feels shortness of breath, as verbalized, “I'm short of breath just sitting here talking”. When asked if there was anything that relieved his condition, Patient H replied, “No, not really.” Patient H also reported to be feverish the night prior to the interview for which he admitted to have one tablet of Tylenol. Patient H furthered that the fever was also associated with chills and sweats, which causes difficulty in sleeping
Medications: Patient H is not taking any medication for any health condition. However, patient reports to self-prescribed Tylenol whenever he feels he is coming up with a flu.

Allergies: Patient H said he is not aware of any allergies that he might have.

Past Medical History (PMH): Patient reported that during his childhood he remembered being diagnosed with primary complex when he was between 8 and 9 years old because he kept having fever every week which alarmed his mother.
Past Surgical History (PSH): Patient H had minor surgery when he accidentally fell off the roof of his house while fixing it in 2010. He received 8 stitches on his chin because of that fall.

Sexual/Reproductive History: Patient H reported that he never experienced any reproductive or sexual problems.

Personal/Social History: Patient H is not married but he lived in with a younger Asian woman for 4 years. Unfortunately, according to him the woman just left. He did not know the reason but he arrived home from work one day and she was no longer there. However, the woman left a letter saying that she needs to be alone. Patient attends Church regularly on Wednesday and Sunday, where he is a member of the choir.
Immunization History: The patient does not have any recollection of immunization except for Hepatitis B which was a requirement from work.
Significant Family History: Patient reported that his parents both were hypertensive. His father died of cardiac arrest after suffering from a stroke when Patient H was 18 years old. His mother, however, died of breast cancer in 1997. Patient H does not have any siblings or offspring.
Lifestyle: Patient H smokes a minimum of 10 sticks of cigarettes a day, but on stressful days he consumes a maximum of 2 packs of cigarette. However, he cannot sleep without drinking at least 3 bottles of beer every night. Patient is also a vegetarian. According to patient, “I cannot tolerate any meat or dairy intake. I will vomit if I do.” Patient also exercise everyday by jogging around his neighborhood for 30 minutes everyday.

Review of Systems:

General: + shortness of breath; + fever with chills and night sweats; no significant weight changes; + productive cough

HEENT: Wet productive cough noted. Throat positive for redness,

Neck: Positive for lymph nodes
Respiratory: Reports of cough with phlegm that is greenish in color, or with blood at times; + shortness of breath at rest and with activity; no history of any respiratory disease.
Cardiovascular/Peripheral Vascular: Blood pressure was 128/70. Heart rate was documented at 82bpm and respiratory rate was recorded at 20 breaths per minute.
Gastrointestinal: Abdomen shows no lump. Negative for any tenderness.
Genitourinary: Patient H reports that he frequently urinates at night causing sleep impairment and disturbances. According to him, “I urinate about 5 to 6 times every night” as verbalized.

Psychiatric: Difficulty of sleeping due to the illness.

Skin: Slightly warm due to fever indicated by a temperature of 100.9oF.
Hematologic: Patient said that he was frequently told that he looked paled and was advised by peers to take iron supplement.
Allergic/Immunologic: Patient reports no known allergy. No allergy test was conducted.

OBJECTIVE DATA:

Physical Exam:
Vital signs: BP: 128/70; HR – 82; RR – 20, labored; T – 100.9oF; Wt. - 210 lbs.; O2 sat – 89%
General: Patient H was alert and oriented. He has full and accurate knowledge of time, date and place when asked. Patient H did not require assistance when walking. He did not manifest any signs of lethargy.
HEENT: Wet productive cough noted. Throat appeared red, perhaps from pressure due to coughing. Eyes were a bit red, according to patient it was irritated this morning.

Neck: Upon palpitation, it was felt that patient H had several lymph nodes on both sides of the neck.

Chest: Upon observation, Patient H’s chest were symmetrical. However, laborious breathing was noted because of the use of accessorial body parts.

Lungs: Breath sounds diminished; rales and expiratory wheezes heard throughout the lungs.

Heart: Regular rate, with good S1 and S2; no S3, S4, or murmur.
Peripheral Vascular: No peripheral edema; 2+ dorsalis pedis pulses palpated bilaterally.

Abdomen: Protuberant with normoactive bowl sounds in all four quadrants.

Genital/Rectal: Genital and rectal exam was not conducted.
Musculoskeletal: Patient is ambulatory, no signs of lethargy or need for any support.
Neurological: No procedure referring to neurologic exam was conducted. However, patient was alert and responded to test for involuntary nerve examination.

Skin: Patient H skin is warm and moist after touch.

Diagnostic Tests:
Chest x-ray – to determine irregularities in the chest structure and lung tissue, and to detect disorders and damages of the lungs (“Diagnostic Tests of the Respiratory System”, n.d).

Blood Tests – to determine presence of infection through white blood cell count (National Heart, Lung, and Blood Institute, 2011).

Other Tests such as Sputum test, CT scan, Pleural fluid culture, pulse oximetry, and bronchoscopy – for patients with serious symptoms (National Heart, Lung, and Blood Institute, 2011).

Differential Diagnosis (DDx):

Pneumonia – progressive cough with greenish secretion with traces of blood streaks.
COPD – patient’s breathing difficulty that is not relieved even when sitting, progressive cough
Asthma – breathing difficulty
Pulmonary edema – presence of progressive coughing with greenish secretion with traces of blood streaks.
Lung Cancer – patient was feverish, history of cancer was present in the family, active smoker which was a risk factor.
Listed diseases possibly present the same manifestations as pneumonia (Hoare & Lim, 2006).
PLAN: This section is not required for the assignments in this course but will be required for future courses.

References

Diagnostic Tests of the Respiratory System. (n.d.). Retrieved from http://wps.prenhall.com/wps/media/objects/3775/3866433/tools/Dia_Tests/TDTNI_Ch36 _p1218-1219.pdf
Hoare, Z., & Lim, W.S. (2006). Pneumonia: update on diagnosis and management. BMJ 332(7549), 1077-9. doi: 10.1136/bmj.332.7549.1077.
National Heart, Lung, and Blood Institute. (2011). How Is Pneumonia Diagnosed? Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/pnu/diagnosis