Term 2 Sample Write Up

ID/CC: KW is a 93-year-old patient with a past medical history significant for myocardial infarctions and recurrent pneumonia who present with recent onset of productive cough for the past 3 days with associated symptoms of unilateral right leg swelling.

HPI: The patient noted that he woke up three days ago with an intermittent cough. He notes that this has happened in the past and is typically pneumonia. When the symptoms first began, they started as a 2/10 in severity. KW reports no fever, chills, ear discharge, pharyngitis, or any other cold symptoms. He does note that the cough is worse while lying down and at night.

When the cough first started, he described it as hacking that later progressed to a rattling sound. He notes that sitting up makes it better. KW tried to alleviate the cough with Aspirin but felt like that did not help. He reports no chest pain, pressure, palpitation, orthopnea, PND, or claudication. He did report that he felt like he was using his entire body to cough and that he started to become hoarse and fatigued from all the coughing.

He was negative for any recent weight changes, diaphoresis, or anorexia. In addition to the cough, KW noted that 2 days ago he had an increase in urinary frequency, urgency, and quantity of urine. He reports no dysuria, hematuria, penile discharge, or testicular pain. He notes that he usually experiences increased urination when he is sick, so this was another indication he had some sort of respiratory infection.

When asked, KW wasn’t sure what was going on because his only symptoms were the productive colorless/odorless cough and increased urination. The pt was negative for wheezing, sleep apnea, hemoptysis, and cyanosis. He does note some dyspnea after he has a coughing fit which quickly resolved. 3 days after his symptoms began, he felt like his coughing became worse (reports it as an 8/10) so he decided to come to the emergency department for evaluation.

KW currently lives at X in the independent part of the facility. When asked, KW reports that one of the other residents he had lunch with had a hacking cough about one week prior to his initial coughing symptoms. He reports no history of asthma or COPD but notes two myocardial infarctions, one 34 years ago and another 3 years ago. At the time of the second MI, he had two stents placed here at Bozeman Health with no complications. He does have a history of hypertension and hyperlipidemia.

Since the cough has started KW has not been able to complete activities he enjoys. He typically rides on a Nordic bike, weight lifts, and does stretching five times weekly and has not been able to do. He is still able to complete 6/6 ADLs and 7/7 IADLs. He has a POLST and DNR in place.

The pt does have a history of smoking but quit 30 years ago (one pack daily for 10 years). He is up to date on all vaccination including Pneumococcal, COVID and flu.

About one month ago KW stated that he was experiencing unilateral leg swelling of his right leg. He sought care at his primary care providers office where they diagnosed him with a “venous problem.” The symptoms were relieved with a compression sock. During this time, he had no trouble walking and denied numbness in any extremities. No past history or family history of DVT or pulmonary embolism.

PMH:

Past Medical History

• Benign Prostatic Hyperplasia, 1985. S/p prostatectomy 1989
• Coronary artery disease: two myocardial infarctions, one 34 years ago and another 3 years ago. S/p CABG in 2021
• Hypertension
• Hyperlipidemia
• Tobacco history. 10 pack year history of smoking. Quit approx. 1994.
• Recurrent pneumonia. Need to determine date of most recent infection.

Past Medical History

• Atorvastatin, unknown dosage
• Lisinopril, unknown dosage
• Aspirin, 81 mg daily

Past Surgical History

• CABG, 2021
• Proctectomy, 1989

Allergies

• No known drug allergies

Health Related Behaviors

• Tobacco: 10 pack year history of smoking. Quit approx. 1994.
• Alcohol: Never
• Recreational drugs: Never
• Sexual history: No STI hx, not sexually active
• Diet: Low sodium, well balanced
• Exercise: He typically rides on a Nordic bike, weight lifts, and does stretching five times weekly but is unable to do so currently due to symptoms.

Preventative health (immunizations, PCP)

• He is up to date on all vaccination including Pneumococcal, COVID and flu.

Family History

• Father—Heart attack, deceased.

Social History

KW retired and moved into the X center about 1 and half years ago. He used to be a professor at X where he taught biology, ecology, anatomy and physiology, and ornithology. He was also a park ranger in X Park and served for many years in the United Stated Army. He lost his wife in 2013 but had been married for 54 years. He has 3 adult children that do not live in the state, but he said he would call them for an emergency. KW lives an active lifestyle. He spends a lot of time being social at X living facility and feels he has a good support system. He is spiritual and considers himself to be Christian.

ROS

General: See HPI

Derm: Negative for pruritus and dermatitis. No changing moles, lumps, or lesions.

HEENT:
Eyes: Negative for cataract lenses, draining tear duct, diplopia. No change in vision, eye pain or inflammation.
Ears: See HPI
Nose: See HPI
Mouth: See HPI

Respiratory: See HPI

Cardiovascular: See HPI

Gastrointestinal: Negative for constipation and nausea. Negative for dyspepsia and dysphagia, negative for hemorrhoids, no vomiting, abdominal pain, jaundice, stool changes, tenesmus, hematochezia, or hematemesis.

Genitourinary: See HPI

Musculoskeletal: Negative for myalgia, joint arthralgias, swelling stiffness. Negative for deformity, no locking of joints.

Neurological: He was negative for headaches, syncope, numbness, ataxia, loss of coordination, and has not had any recent falls.

Psychiatric: negative for dysphoria, insomnia, and anxiety.

Hematologic: Negative for bruising, prolonged bleeding, anemia

Endocrine: Positive for polyuria and polydipsia.

Functional status: See HPI

Physical Exam:

Vital Signs: BP: 174/73 P: 99 R: 18 O2: 96, Afebrile per nurse
Complete physical exam not completed.

General: Well appearing, in no acute distress, oriented to person place and time. No visible skin lesions. Saline lock on the right hand. Slight raddles heard when coughing. Patient was seated in chair.

Skin: Warm, dry. Clear without rashes or lesions, nails (without clubbing, cyanosis, or lesions)

Chest: Breathing comfortably, symmetric chest expansion. Resonant to percussion bilaterally. Clear symmetric breath sounds with adventitious sounds of bronchial wheezes present in R and L lower lung field. Symmetric tactile fremitus and no egophony bilaterally.

Cardiac: PMI nondisplaced at left MCL. Regular rate and rhythm. Audible S1 and S2, no murmur. Bilateral carotid pulses without bruits. Radial, femoral, dorsalis pedis, and posterior tibial pulses bilateral and symmetric. No edema in bilateral lower extremities.

Summary statement: KW is a 93-year-old patient with a past medical history significant for a coronary artery disease with most recent myocardial infarction 3 years ago and recurrent pneumonia who present with recent onset of productive cough with colorless phlegm for the past 3 days with associated symptoms of unilateral right leg swelling for the past month. Physical exam pertinent for breath sounds with bronchial wheezes present in R and L lower lung field and hypertension. Differential dx includes pneumonia, bronchitis, pulmonary embolism, medication side effects.

Assessment: Given the patient’s rapid onset of productive cough the most likely diagnosis is pneumonia or bronchitis from a viral pathogen. The pt. recently had a sick contact, has a history of pneumonia in the past and the progressively worsening cough. The pt. does not note a fever or other severe cold symptoms making viral bronchitis more likely. In addition to this, on exam he has bronchial wheezes which were present in both the R and L lower lungs fields. Dyspnea was noted by the patient once the coughing became worse. However, the timeline and no sharp pleuritic pain and no focal findings such as decreased tactile fremitus or egophony noted making a focal bacterial pneumonia less likely.

Pulmonary embolism was thoughtfully considered due to the patient’s recent unilateral leg swelling, age and dyspnea. However, the pt. did not experience any chest pain. The patient reports no personal or family history of DVTs. There were no signs of unilateral edema on exam today making DVT less likely and no obvious recent immobility. While this is something that cannot be missed, the fact that the patient has no pleuritic chest pain, hemoptysis, unilateral leg swelling, makes DVT and pulmonary embolism less likely.

Lisinopril was thought to be a potential cause of his cough due to limited other symptoms reported by the patient. However, this side effect is typically a dry cough and usually appears within the first weeks to months of use. He also reported dyspnea with the cough making this less likely.

Plan:

• Obtain CXR or CT of chest for evaluation to evaluate for any potential fluid/air collections/masses.
• Obtain O2 saturation, start 2 liters of O2 via nasal canula if O2 stat falls below 90%.
• Start Albuterol 2.5 mg in nebulizer 1-2 times daily to improve respiratory function and prevent respiratory fatigue.
• Give Dextromethorphan 20 mL every 4 hours to relieve cough and throat irritation.
• Consider withholding Lisinopril in attempt to see symptom relief. Switch patient to Losartan 50 mg daily if cough was relieved by holding Lisinopril. This may need to be done in the outpatient setting.
• Complete full cardiovascular workup should be completed to rule out other cardiovascular etiologies including heart failure. This would include checking for elevated jugular venous pulsations and listening for S3 on exam. The abscence of crackles on lung exam and no lower extremity edema decreases the liklihood of congestive heart failure as the cause.
• Order CBC with diff, d-dimer to evaluate for pulmonary embolism, infection and anemia.
  • Consider iron studies if abnormal hemoglobin levels arise from CBC.
• Attempt to get a sputum culture.
• Consider starting antibiotics (Azithromycin 250 mg daily) and acetaminophen (600 mg daily) if patient develops fever or increased discolored sputum with increased WBC count.
• The patient’s remaining hospital course with focus on symptom management and clearing infection.
• Pt is to return to skilled nursing facility once symptoms have been relieved and infection is no longer present.

References

Lee. G., Broaddus, C., Finlay, G. (June 2023) Pneumothorax in adults:  Epidemiology and etiology. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. http://www.uptodate.com (Accessed on May 5, 2024.)

Means, R., Bordsky, R., Elmore, J., Tirnauer, J., Givens, J. (April 2024) Diagnostic approach to anemia in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. http://www.uptodate.com (Accessed on May 5, 2024.)

Ramirex, J., File, T., Bond, S., Dieffenback, P. (March 2024) Overview of community-acquired pneumonia in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. http://www.uptodate.com (Accessed on May 5, 2024.)

Thomas, F., Sexton, D., Aronson, M., Givens, J., Bond, S. (Dec 2023) Acute bronchitis in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. http://www.uptodate.com (Accessed on May 5, 2024.)

Thompson, T., Kabrhel, C., Pena, C., Mandel, J., Zachrison, K., Finlay, G. (March 2024) Maughan L. Karen, MD. (Sep. 2023) Ankle sprain in adults: Evaluation and Diagnosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. http://www.uptodate.com (Accessed on May 5, 2024.)

Townsend, R., Bakris, G., Elliott, W., Forman, J. (March 2024). Major side effects of angiotensin converting enzyme inhibitors and angiotension 2 receptor blockers. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. http://www.uptodate.com (Accessed on May 5, 2024.)