Subjective Information
- Date: 06/23/2019
- Source of information: Patient
- Gender: Female
- Age: 45 years old
- Location: Clinic
- Level of reliability: High
C/C: “I have been coughing for two weeks.”
HPI: This is a 45-year-old African American female who presents here today with complaints of cough 8/10. The patient reports chest discomfort 7/10 severity and chills X2 a day. Over the past two weeks, she has noticed the production of white mucus several times. A week ago, she had a fever of 101 with relief of over-the-counter Tylenol 500 mg two times every five hours that day. Associated symptoms include expressive fatigue and occasional shortness of breath. The patient denies nausea, vomiting, headache, abdominal pain, or blood in the mucus. She is sexually active; the last OB/GYN exam was in February.
PQRST: The patient was tending to flowers in her garden at the time of onset. She describes the cough as “barking” and says that she has been feeling much worse over the past three days. The pain is in the chest, but it radiates to the lungs. The patient rates her pain at 8/10, and discomfort – at 7/10. She reports having had the symptoms for two weeks, and she has noticed that drinking cold water makes the cough worse.
Review of Systems
GENERAL: The patient does not report any major health changes apart from the cough.
HEENT: Eyes: near-sightedness. Ears, Nose, Throat: normal hearing, no throat pain, no abnormal nose discharge.
SKIN: no itching or rash.
CARDIOVASCULAR: occasional pain in chest; no oedema or palpitations.
GASTROINTESTINAL: no loss of appetite, no vomiting, or diarrhea, nausea, or anorexia. No abdominal pain or blood.
PMH: In their teenage years, she was treated for food poisoning and inflammatory bowel disease. In 2006, she had postpartum depression after giving birth to her first child. The patient also has chronic headaches and type 2 diabetes.
PSH: She had laparoscopic appendix removal in 2000 and a Cesarean section in 2009.
Allergies: The patient reports allergies to peanuts and milk; she has been avoiding these products since a very early age. She denies allergies to medications or any other food allergens.
Medications: Headaches: Naproxen 250 mg PO; frequency depends on the severity of headaches. Type 2 diabetes: Metformin with a meal 2X a day.
Family Hx: The patient’s father died of congestive heart failure, and her paternal grandmother had lung disease.
Social Hx: The patient is married and has two children (aged 10 and 13). Her husband is the breadwinner, but she also has a part-time job as a copywriter. She is a member of the local Moms’ Club and attends church every Sunday. She is frequently asked to participate in her children’s school talent shows because she can play the piano and violin. The patient enjoys family gatherings and loves spending time outside. She is outgoing, friendly, sociable, cheerful, and is always ready to help others.
Smoking: She smoked in her early twenties, but then quit and never started again.
ETOH & Illicit Drugs: none.
Living Environment: The patient’s family has a semi-detached house in the suburbs. Their home is spacious and has access to much natural light. They have a large yard, which is the place of their dog’s house as well as the venue for family games at the weekend. There is a factory producing plastic details for bags and backpacks nearby. The patient’s husband smokes about 10 to 15 cigarettes a day.
Objective Information
Vital Signs: BP 115/75, HR 85, RR 17, Temp 96.2 (oral), SPO2 96% RA.
Height: 5ft 8inch, Weight: 143 lb., BMI: 21.7.
Recent Labs: EKG, January 2019, normal.
General Survey: This is a well-developed, well-nourished African American female that appears younger than the stated age. Her speech is clear, and her answers are congruent with questions. The woman is dressed neatly and appropriately for today’s weather. The patient is calm, and she does not appear to be in distress.
Physical Exam
LUNGS: Resonant throughout. Clear to auscultation bilaterally. Fremitus equal bilaterally. Breath sounds vesicular.
THORAX: Symmetrical with even expansion, no bony deformities, AP diameter is not increased, there is no tenderness. No supra/infra, axillary, or lymphadenopathy.
HEART: No lifts, heaves, or thrills. PMI 5th LICS at MCL, Regular S1, S2, no S3 or S4. No murmurs rub gallops or clicks.
CHEST: Diaphragm appears lower and flatter.
ABDOMEN: Symmetrical, flat with no lesions, scars, herniations, or abnormal pulsations. The abdomen is soft, with normoactive bowel sounds in all four quadrants. There are no bruises or hums.
LIVER: Is palpable.
BACK: Normal curvature, positive bilateral costovertebral angle (CVA) tenderness.
HEENT: Head normocephalic; eyes clear, no difficulty focusing; ears clean; no pain in the neck; throat clear.
Assessment
Diagnosis: The primary diagnosis is acute bronchitis (ICD-10: J20.9) (“2019 ICD-10-CM Diagnosis Code J20.9,” 2018).
Rationale
Based on symptoms such as prolonged severe cough, chest discomfort, mucus, and fatigue, it seems most relevant to diagnose the patient with bronchitis (Kinkade & Long, 2016). The patient has a family history of heart and lung disease, which necessitates thorough attention to the presented symptoms and allows presuming this diagnosis. Diaphragm appearing lower and flatter is another sign of bronchitis. The liver is palpable, which means that it could have been displaced due to overinflation. Since the patient’s husband is a heavy smoker, she is at an increased risk of developing bronchitis. It is necessary to perform a lung function test and make an X-ray. Also, it is important to order some blood tests and check mucus to exclude the illnesses caused by bacteria.
Differential Diagnoses
Pneumonia due to Mycoplasma pneumoniae
A possible differential diagnosis for the patient is pneumonia (ICD-10: J15.7) (“2019 ICD-10-CM Diagnosis Code J15.7,” 2018).
Rationale
The patient presents such symptoms referring to pneumonia as respiratory problems and occasional fever. However, patients with pneumonia typically have a much higher fever than those with acute bronchitis. Also, pneumonia is associated with bacterial causes whereas acute bronchitis is not (Musher, Abers, & Bartlett, 2017). Therefore, to confirm or reject this diagnosis, it is necessary to perform lab tests to rule out the bacterial origin of the patient’s cough. Since a greatly increased importance of respiratory viruses is one of the major trends in determining pneumonia’s agents, it is crucial to check the patient for viruses (Musher et al., 2017).
Asthma
Another possible diagnosis for the patient is asthma (ICD-10: J45) (“2019 ICD-10-CM Diagnosis Code J45,” 2018).
Rationale
As well as bronchitis, asthma affects the person’s lower respiratory tract. This disease is characterized by occasional or frequent symptoms of cough, dyspnea, and wheezing (McCracken, Veeranki, Ameredes, & Calhoun, 2017). Also, asthma is often associated with allergies, which the patient denies. Clinical and family histories allow concluding that the patient is more likely to have acute bronchitis than asthma. Furthermore, the major difference between acute bronchitis and asthma is the chronicity of bronchospasm. Since bronchospasm is not frequent in the patient and since she has no wheezing or dyspnea, it is relevant to consider asthma only as a differential diagnosis.
Chronic obstructive pulmonary disease
The third differential diagnosis is COPD (ICD-10: J44.9) (“2019 ICD-10-CM Diagnosis Code J44.9,” 2018).
Rationale
COPD is similar to bronchitis and asthma in that it also involves lower respiratory tract infections and may lead to lung function decline (Barnes, 2016). COPD is generally characterized by the limitation of progressive airflow limitation (Barnes, 2016). Meanwhile, the patient does not report such symptoms. Additionally, her condition developed two weeks ago, while COPD requires more time to evolve. Hence, it is possible to view this diagnosis only as an additional differential one.
Plan
Medications
- Start Azithromycin 500 mg PO once, then continue at 250 mg once daily X 4 days. Azithromycin has proven to successfully fight bacteria, which may be the cause of bronchitis development. Evidence-based research reports that antibiotic treatment has a positive effect on acute bronchitis relief (Llor & Bjerrum, 2016). Since the patient has no medication allergies, she may be prescribed this drug.
- Continue Naproxen 250 mg PO and start combining it with Sumatriptan for better effect. According to Law, Moore, and Derry (2016), the combination of these drugs leads to better clinical outcomes.
- Continue Metformin with a meal 2X a day. Research indicates that this drug is one of the most effective medications for type 2 diabetes patients (Maruthur et al., 2016).
Labs
A blood test to confirm or reject an infection; a chest X-ray to check the bronchial tubes and lungs and confirm or rule out pneumonia; a respiratory mucus analysis to analyze the origin of mucus; a urine test to check for other possible infections of inflammations.
Diagnostics: Spirometry to check the patient’s lung function. With this diagnostic measure, it will be possible to check how much air the patient’s lungs can hold and how fast she can blow it out. The rationale behind this method is to see whether there are any other breathing problems aside from bronchitis.
Referrals: The patient has been referred to the respiratory physician for baseline assessment within the nearest two days.
Patient Education
- Medication teaching for Azithromycin and Sumatriptan including the potential side effects (agrees);
- Increase fluids intake, drink warm beverages at least five times a day (agrees);
- Take antibiotics exactly as prescribed without skipping the dose or ceasing even if she notices that symptoms have relieved (agrees);
- Avoid alcohol and cold drinks (agrees);
- Avoid breathing cigarette smoke (agrees but says it might be difficult to convince her husband to stop smoking next to her);
- Call the doctor’s office in case any new symptoms develop or old ones are aggravated (agrees);
- The patient was given the handout on acute bronchitis and requested to read it and follow the recommendations given in it (“Acute bronchitis, 2016) (agrees).
Follow-Up
The patient should come back in a week. By then, the doctor will have received all lab and test results, diagnostics, and feedback from the referred specialist. At the next appointment, the patient will report on the effectiveness of the medication, as well as inform the physician about any positive or negative changes following the education plan.
References
Acute bronchitis. (2016). Web.
Barnes, P. J. (2016). Inflammatory mechanisms in patients with chronic obstructive pulmonary disease. The Journal of Allergy and Clinical Immunology, 138(1), 16-27.
Kinkade, S., & Long, N. A. (2016). Acute bronchitis. American Family Physician, 94(7), 560-565.
Law, S., Moore, A., & Derry, S. (2016). Sumatriptan plus naproxen for the treatment of acute migraine attacks in adults. London, UK: Cochrane Database of Systematic Reviews.
Llor, C., & Bjerrum, L. (2016). Antibiotic prescribing for acute bronchitis. Journal Expert Review of Anti-Infective Therapy, 14(7), 633-642.
Maruthur, N. M., Tseng, E., Hutfless, S., Wilson, L. M., Suarez-Cuervo, C., Berger, Z., … Bolen, S. (2016). Diabetes medications as monotherapy or Metformin-based combination therapy for type 2 diabetes: A systematic review and meta-analysis. Annals of Internal Medicine, 164(11), 740-751.
McCracken, J. L., Veeranki, S. P., Ameredes, B. T., & Calhoun, W. J. (2017). Diagnosis and management of asthma in adults. JAMA, 318(3), 279-290.
Musher, D. M., Abers, M. S., & Bartlett, J. G. (2017). Evolving understanding of the causes of pneumonia in adults, with special attention to the role of pneumococcus. Clinical Infectious Diseases, 65(10), 1736-1744.
2019 ICD-10-CM Diagnosis Code J15.7. (2018). Web.
2019 ICD-10-CM Diagnosis Code J20.9. (2018). Web.
2019 ICD-10-CM Diagnosis Code J44.9. (2018). Web.
2019 ICD-10-CM Diagnosis Code J45. (2018). Web.