Patient information:
Initials LB
Age: 58
Sex: male
Race: white
S.
Cc (chief complaint): “I have been coughing for the past four days.”
Hpi:
Mr. L.B., a 58-year-old white male, came to the facility with complaints of cough for the past four days. He reports the cough to be intermittent, initially dry but has progressed to coughing up thick yellow phlegm. The cough worsens whenever he smokes, thus reducing his smoking habits in the last few days. He reports to be feeling tired. He has taken Tylenol off and on, but it relieves symptoms slightly. He reported having played poker with some friends a week ago, and one of them had similar symptoms. He suspects having a fever but has not measured his temperature and denies any confusion.
Current medications:
Lisinopril 20 mg daily
Metformin 500 mg twice daily
Allergies: The patient is allergic to penicillin.
Pmhx:
Hx of hypertension
Diabetes mellitus type 2
He is noncompliant with medical appointments; their last visit was around seven months ago, but he has a year’s supply of medications that he has not run out of.
Soc & substance hx:
Hx of cigarette use
No history of alcohol use
No smoke detectors in their house.
Fam hx: No history of chronic mental illnesses in the family
Second, born in a family of three.
Surgical hx: No history of surgical intervention
Mental hx: No history of mental health illnesses
No history of suicidal ideation.
Violence hx: No history of police arrest.
Reproductive hx: Heterosexual
Married monogamously.
Ros:
General: He appears in fair general condition. Reports feeling tired. Denies weight loss, chills, or weakness.
Heent: Eyes: no diplopia, visual loss, or blurred vision. Ears, nose, and throat: No hearing loss, congestion, sneezing, sore throat, or runny nose.
Skin: No rash or itching.
Cardiovascular: No palpitations, chest pain, or chest discomfort.
Respiratory: cough, thick pale yellow phlegm.
Gastrointestinal: No nausea, vomiting, anorexia, or diarrhea.
Genitourinary: No pain or itchiness on urination.
Neurological: No headache, dizziness, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
Musculoskeletal: No muscle or joint pain or numbness.
Hematologic: No anemia, bleeding, or bruising.
Lymphatics: No history of hepatosplenoctomy or enlarged nodes.
Psychiatric: No history of anxiety or depression.
Endocrinologic: No polydipsia, polyuria or cold, or heat intolerance. Reproductive: heterosexual.
Allergies: Penicillin allergy.
O.
Physical exam: vitals: height: 5’4″, weight: 190 lbs, blood pressure: 150/94 mmHg, pulse: 88 bpm, respiratory rate: 26 breaths per minute, temperature: 101°f
General: The patient appears tired.
Respiratory: Auscultation reveals coarse breath sounds bilaterally, with occasional rhonchi and crackles. Increased tactile fremitus is noted.
Cardiovascular: regular rate and rhythm, no murmurs or extra heart sounds.
Diagnostic results: n/a
A.
Differential diagnoses:
- Acute bronchitis is an inflammation of the bronchial tubes (Morley et al., 2020). It is commonly caused by a viral infection, such as influenza or respiratory syncytial (RSV). Although in some cases, it can be triggered by bacterial infections or irritants. Its symptoms include persistent cough (dry or productive (producing phlegm)), chest discomfort or tightness, fatigue, sore throat, and low-grade fever in some people (Morley et al., 2020). Management includes self-limiting, adequate rest, fluid intake, and over-the-counter pain relievers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Smoking cessation also helps improve lung health and exacerbations. This is the likely diagnosis as the patient’s cough with yellow phlegm, fatigue, and history of exposure to a sick individual.
- Community-acquired pneumonia (CAP) is a lung infection outside healthcare settings. It is caused by bacteria such as streptococcus pneumoniae but can also be caused by viruses or, less commonly, fungi (Li et al., 2020). Its symptoms include cough-producing phlegm, high-grade fever, chest pain, sweating, and confusion. This is a likely diagnosis given the patient’s cough, fever, and fatigue but ruled out as the patient denies chest pain, high-grade fever, and confusion.
- Chronic obstructive pulmonary disease (COPD) exacerbation refers to worsening symptoms and lung function in individuals with underlying COPD. It is triggered by respiratory infections, irritants, or factors causing airway inflammation and narrowing (Stolz et al., 2022). Symptoms include increased breath shortness, persistent cough, chest tightness, fatigue, and changes in mental status. Treatment includes bronchodilators, systemic corticosteroids, antibiotics, and oxygen therapy (Stolz et al., 2022). Vaccination against influenza and pneumococcal infections also prevent respiratory infections. This is a likely diagnosis due to the patient’s smoking history and persistent cough but was ruled out as the patient does not have reported changes in mental health status or even breathing shortness.
The plan includes conducting diagnostic studies such as a chest x-ray to evaluate for possible pneumonia. Perform a complete blood count (CBC) to assess for leukocytosis and sputum culture if symptoms persist or worsen (Ryu et al., 2020). Therapeutic interventions will include advising the patient to quit smoking and connecting him to cessation resources. Also, recommend bed rest, increased fluid intake, and over-the-counter cough suppressants. LB will also be educated about the importance of regular follow-ups with his healthcare provider to manage better his chronic conditions and advice on prompt medical attention if symptoms worsen or persist. He will be referred to a pulmonologist for further evaluation and management of respiratory symptoms. A follow-up appointment will be scheduled in one week to assess the patient’s progress and evaluate the need for further interventions.
Health promotion and disease prevention
The health promotion plan will include smoking cessation strategies and their contribution to overall health improvement, especially in managing respiratory symptoms and future exacerbations. As a 58-year-old, Mr. Brown may have been smoking for a significant portion of his life. Hence smoking cessation strategies include counseling and referring him to programs that offer behavioral interventions. These interventions can help him identify triggers, coping mechanisms and set achievable goals for quitting smoking. Discuss the pharmacological options for smoking cessation, such as nicotine replacement therapy (NRT) or prescription medications like bupropion or varenicline (Ryu et al., 2020). Encourage Mr. LB to seek support from family, friends, or support groups. Connect him to local smoking cessation support groups or online communities where he can connect with others who are also trying to quit smoking. The provider must ensure that this approach respects and acknowledges Mr. LB’s cultural background, beliefs, and preferences related to smoking.
Reflection
This case has taught me the importance of taking a comprehensive health history and performing a thorough physical examination to develop an accurate differential diagnosis. It also indicates the significance of regular healthcare provider visits and adherence to medication regimens for patients with chronic conditions. Additionally, the case reinforces the role of health promotion in addressing modifiable risk factors, such as smoking, to prevent disease progression and improve overall health outcomes.