Review of Case Study 3Patient Information: Name: Mr.Hendrix, Age: 65, Sex: M, Race: CaucasianS.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 andsays 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) inhibitorAllergies: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 asthmaNo prior history of cancerNo prior history of human immunodeficiency virus (HIV).Pt is a smokerSoc 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.