Subjective data
Patient Initials: Name: ABC, Age: 65, Race: Caucasian
CC: ‘For the past ten weeks, I have been having difficulty in breathing, cough, and wheezing.”
HPI: The patient is a 65-year-old Caucasian woman who presented to the clinic in the morning with initial complaints of cough, wheezing, and difficulty breathing for the past ten weeks. She states that her symptoms have worsened and occurred at least once a day. The cough, however, is non-productive associated with wheezing and difficulty in breathing. She states that her symptoms are aggravated by physical activity, and wheezing occurs when difficulty in breathing is experienced. She adds that she had a positive history of trauma ten weeks ago, and she has been on phenytoin for post-traumatic seizures. She is also a known asthmatic on albuterol and CJF patients under enalapril and HCTZ.
PMH: Known as asthmatic since her early 20s, CHF for three years. Current medications include Enalapril 5 mg PO BID, Theophylline SR Capsules 300 mg PO BID, Albuterol inhaler, PRN, Phenytoin SR capsules 300 mg PO QHS, and HTCZ 50 mg PO BID. She has no known allergies or surgical history.
FH: Mother succumbed at 62 years from CHF, and father at age 59 due to HTN.
SH: Denies smoking nor use of alcohol. She is an occasional caffeine user.
R/S: General: The states that she has problems breathing and has wheezing and cough. However, she denies fever, fatigue, seizures, or any other symptoms. CVS: She has exercise intolerance, cough, and periodic difficulty in breathing. Denies palpitations, chest pain, orthopnoea, or any problems with her consciousness. Res: She is optimistic for difficulty breathing, cough, and wheezing. She denies sputum production, chest pains, or any other positive symptoms. GIT: Denies nausea, vomiting, heartburn, chest pains, or abnormal bowel habits. GUT: She is post-menopausal, denies dysuria, haematuria, or any per vaginal discharges. Musc: denies muscle pain, stiffness, joint swelling, crepitus, arthritis, and decreased range of motion. Neuro: She is only anxious but denies any headaches, low balance, or speech problems. Psych: Denies any stress, PTSD, depression, paranoia, nor any issues concentrating pr on her memory.
Objective data
V/S: HR 122, Ht 5’3”, Wt 145, BP 171/94, RR 31, and after use of albuterol, vital signs indicate BP 134/79, RR 18, HR 80.
Physical Assessment
General: She is very anxious, appears pale but is oriented to place, person and time. She is in mild respiratory distress, but appears well-nourished, is well organized, responds well to the assessments, and is very cooperative. CVS: Regular heart rhythms with S1S2 normal without any additional heart murmurs. Chest: Positive for bilateral expiratory wheeze. Abd: non-tender, soft, no scars, moves with respiration and has no organomegaly. GU: Unremarkable. Rectal: Guaiac negative. Ext: +1 ankle edema on the right lower limb, pulses normal, and no bruising. Neuro: oriented and alert with intact cranial nerves.
Results of diagnostic test: The peak flow rate is 75/min, and after using albuterol, it increased to 102/min. FEV1-1.8; FCV 3.0, FVC 60%. K 4.9, Na 134, Cl-100, BUN 21, Cr 1.2, Glu 110, ALT 24, AST 27, Total chol 190, CBC-WNL, Theophylline 6.2, Phenytoin 17. Chest x-ray shows features of blunting on the left and right costophrenic angles. Normal lab tests with chest X-ray features of blunted costophrenic angles suggesting signs of pleural effusion.
Assessment
Her current subjective and objective assessments make her more liable to the following diseases.
- 8 Pleural Effusion
- ICD-10-150.9 Heart Failure Unspecified
- 9 Unspecified Pneumonia
These are the patient’s most likely differential and diagnoses (Lanks, Musani & Hsia, 2019).
Dx1: J91.8 Pleural effusion
The blunting of both the left and right costophrenic angles on chest X-rays indicates this is the most specific diagnosis. A chest x-ray is utilized to diagnose it, as are the cardinal respiratory symptoms of shortness of breath, non-productive cough, and wheezing. A leak of transudate fluid into the pleural space might increase pleural fluid (Jany & Welte, 2019). Diuretics, increasing doses of hydrochlorothiazide, hydralazine, and bronchodilators used in concert with long-acting steroids are all necessary drugs. If issues emerge, pleural tapping might drain excess pleural fluid. Health educators will discourage moderate physical activity until all symptoms have been addressed. Additional nutrition education is necessary for a healthy diet, smoking cessation, and alcohol use (Jany & Welte, 2019). A medical outpatient clinic with twice-weekly sessions is used for follow-up. Currently, recommendations are not required.
Dx2: ICD-10-150.9 Heart Failure
The presence of respiratory pain and significant edema in the lower limbs raises the possibility of heart failure as a differential diagnosis. It is suggested that diuretics, beta-blockers, and an antihypertensive drug be utilized (Inamdar & Inamdar, 2016). The patient education program will be part of physical exercise, stopping smoking, eating a low-sodium diet, and decreasing weight. Follow-up requires monthly visits to a medical outpatient facility.
Dx3: J18.9 Pneumonia
Pneumonia is a differential diagnosis that needs laboratory testing to rule out. If a nasty bacterium is discovered, antibiotics such as ceftriaxone and amoxicillin will be administered (Lanks, Musani & Hsia, 2019). Patient education will cover avoiding cold temperatures, oral rehydration therapy, and bronchodilators for respiratory comfort.
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