Review of Case Study 3
Patient Information:
Name: Mr.Hendrix,
Age: 65, Sex: M, Race: Caucasian
S.
CC
: “Cough that is getting worse”.
HPI
: Pt is a 65 year old CM who states has a cough that is bringing up secretions that are green
and thick. Says is hard to brink them up but when he does the secretions are thick with blood and
says he ‘brings up’ about 1 teaspoon per day and it has an odor that is foul.Pt states walking
makes his shortness of breath worse( Location) . Pt also states he is short of breath during this
interview also. Nothing seems to make his cough better. Pt states he thought he was coming
down with a fever last night and chills and therefore took some Tylenol. Pt shares that it ‘took
forever’ to get to sleep. Says this is the first time he has had these symptoms.
Pt also states his
cough began 5 days ago (Onset). Cough is a dry hacking cough and painful to intercostal
muscles(Character). Cough brings on other (Associated) signs and symptoms such as a slight
headache and runny eyes with some pain from the musculature due to coughing. Sdays cannot
catch his breath when coughing and that is frightening. Patient is coughing before sleeping, and
it will wake him up from his sleep( Timing). Also says the cough is chronic not intermittent.
(Exacerbating/ relieving) factors; Tylenol has not helped (Relieveing/Exacerbating) and he has
not tried anything else but states, “ noghitng has helped”. (Severity) of the cough on a scale of
1/10;1 being coughing with no pain and 10 being intercostal muscles hurting with coughing was
5/10.
Pt says his symptoms occur everywhere (environment). Pt has no one else in his family
that is ill, but his partner on the assembly line has been sick and is on antibiotics.
Current Medications
:
Pt uses Triamcinolone Acetonide Ointment ( Triamcinolone ), thin film per application, 2
to 4 times daily. Has been using for last 2 months for excema.
Multivitamin, Centrum for Men 50+ , one tablet daily for supplement.
Pt does not take any angiotensin converting enzyme (ACE) inhibitor
Allergies:NKDA , NKFA ,
Allergic to cats, causes itching to extremeties.
PMHx
:
Pt unsure of last tetanus shot.
Immunizations are up to date.
Appendectomy two years ago.
No prior history of heart failure.
No prior history of asthma
No prior history of cancer
No prior history of human immunodeficiency virus (HIV).
Pt is a smoker
Soc Hx
: Pt works on an assembly line at a factory that produces car parts. Pt smokes 3 cigarettes
a day. Brother and Father smoke cigarettes ; one pack a day. Alcohol is used socially at family
gatherings once a month at 5 drinks an occasion. Pt does smoke inside his home. Possible
exposure to TB at the nursing home is father is at.
