- Patient: M. J.
- Date of birth: August 29, 1950
- Sex: female
- Race: white
- Date of presentation: October 26, 2017, 2:30 pm
- History and examination taken: October 26, 2017, 2:30 – 3:30 pm
- Informant: patient
Chief Complaint
The patient has had a fever and cough for a week. Cough is followed by severe chest pain.
Subjective
HPI. The patient is a 40-year-old woman. She has been married for 40 years and has four children. She has been observing fever and cough for a week already. The patient experienced a fever heat of 102. She has been taking ibuprofen once or twice a day for fever during the recent week, but it did not help much. Every time she coughs, there is sputum which is “rusty looking.” The patient admits that she often needs to take a deep breath to help her when she coughs. She complains of a disability to do any indoor or outdoor activities because any effort makes the cough worse. The patient also admits that the cough does not let her sleep normally. Moreover, the woman observes sharp pain in her chest when she coughs. She denies pain when not coughing. The patient constantly feels tired. Although she has not been eating much, she has not lost weight. The woman does not complain of headaches, fatigue, or muscle aches. There are no signs of nasal congestion. The patient denies ear pain.
Previous visit: four months ago, for a regular visit. There were no complaints at the time of the visit. No history of surgery. Was hospitalized four times when pregnant, four vaginal deliveries. No hospitalization since her younger child was born.
Allergies: no detected allergies, either drug or food.
Did not take a flu vaccine. Refuses to get a flu shot because she is not feeling well enough. The patient has never received a pneumonia vaccine. She had a TB skin test four months ago, which was negative.
Medicines taken: the patient was taking 2 tsp of rubutsen every 6 hours and a 200 mg dose of ibuprofen.
Habits: the patient has been smoking a pack of cigarettes a day for 45 years. She drinks a cup of coffee a day. No history of drug use.
Family history: no asthma, cardiovascular disease, cancer, hypertension, or other chronic diseases. At present, no one else in the family is ill or has similar symptoms.
Social issues: She is a retired school teacher and does not work at the moment. She lives with her husband. The patient does some knitting as a hobby. Her sports activities include rare visits to the gym and senior water aerobics 2-3 times a week for one hour. Last menstrual period at the age of 51.
Review of systems
General: The patient had a fever and decreased appetite. Denies fatigue. She has had problems with sleep during the week because of a cough. Admits pain in the chest during cough. Has not been exposed to no TB. No traveling has been done.
Respiratory: Cough is sharp all day, constant color sputum, no shortness of breath on exertion, no hematemesis. Rusty color of sputum, no signs of blood.
Skin: denies rushes or lesions.
HEENT: eyes – no changes in vision.
Ears – Has no numbness or tingling.
Nose/throat/mouth/teeth – No swollen nose, head or neck. No itchy sore throat. No neck stiffness.
Cardiovascular: chest pain. No heartburn.
Breasts: denies pain, no visual changes.
Gastrointestinal: No abdominal pain.
Genito-urinary: No complaints. Last menstrual period at the age of 51.
Neurologic: Denies headaches, seizures, or weakness.
Musculoskeletal: No pain in legs when walking.
Endocrine: denies diabetes.
Objective
Physical Examination
Vital signs: temp 37.5°C, BP 130/85, pulse 67, RR 19, 98% on RA.
General: pleasant 67-year-old female, quiet but stressed because of severe cough that interferes with her sleep.
Skin: no rashes or lesions.
Lymph nodes: No lymphadenectomy.
HEENT: eye redness, oropharynx clear.
Neck: no abnormalities.
Chest and lungs: decreased intensity of breath sounds, wheezes.
Heart: clear, regular murmur.
Abdomen: soft.
Musculoskeletal: no joint inflammation, no abnormalities.
Nervous system: the patient is oriented and alert, pupils reactive. Speech is clear.
Assessment
Primary diagnosis: Pneumonia, unspecified organism, ICD-10-CM Diagnosis Code J18, (“2017/18 ICD-10-CM Diagnosis Code J18.9,” n.d.). The usual symptoms of pneumonia are chest pain (particularly whole breathing or coughing), cough with sputum, fever, shortness of breath, and fatigue.
Differential Diagnoses
Bronchitis (ICD-10-CM Diagnosis Code J40). The symptoms include cough, production of sputum, fatigue, slight fever, discomfort in the chest, and shortness of breath. However, the patient admitted severe cough and high temperature, so pneumonia is a more likely diagnosis.
Chronic obstructive pulmonary disease (ICD-10-CM Diagnosis Code J44.1). It is characterized by shortness of breath, tightness in the chest, a chronic cough that produces sputum, and wheezing. Nevertheless, the patient has been observing cough for a week, so it is not chronic.
Pulmonary edema (ICD-10-CM Diagnosis Code J81.0). Its symptoms are dyspnea and shortness of breath, anxiety, wheezing, irregular heartbeat, and cough with sputum. Still, the patient does not observe dyspnea, irregular heartbeat, or anxiety. Thus, this diagnosis is the least probable for the patient.
Health Promotion Issue
A health promotion issue that needs to be addressed is nicotine dependence (ICD-10-CM Diagnosis Code F17.200). The patient should stop or significantly decrease the number of cigarettes she smokes because nicotine negatively influences the respiratory system affected by the disease.
Plan
- The patient has to take an X-ray examination.
- Blood test to detect an infection and determine its type
- Pulse oximetry
- Sputum test to reveal the cause of infection
- In case an X-ray is not informative, a CT scan is necessary
- Pleural fluid culture investigation to define the infection type (“Pneumonia: Diagnosis,” 2017).
- Hospitalization is recommended because of age.
After the results of all tests are available, the treatment can be prescribed with the consideration of the defined type of infection.
Treatment
- Antibiotics: used in case bacterial pneumonia is proved. The possible antibiotics approved by contemporary research (Gamache, Harrington, & Kamangar, 2017):
- Azithromycin
- Cefepime
- Cefotaxime
- Amoxicilline
- Levofloxacin
- Erythromycin, etc.
- Respiratory support
- Analgesic medication to reduce chest pain
Patient education
- Explain the negative impact of smoking and provide assistance in giving up smoking
- Recommend having rest with enough sleep
- Explain the specific breathing technique to get mucus out of the lungs
- Provide hygiene recommendations
- Suggest a balanced diet
- Recommend an intensive drinking regime to loosen up mucus.
Return to Clinic: The patient has to return to the clinic in seven days to assess her condition and the treatment progress. In case the medication is not effective, treatment strategy has to be changed. If during the first three or five days of medical treatment the symptoms do not decrease or even worsen, the patient should not wait for seven days and return to the clinic as soon as possible. Hospitalization can be necessary in case home treatment is not effective. Repeated tests and X-ray is necessary to evaluate the treatment progress.
Signature (name, specialty, position).
CTP Billing
History: billing code 99213 (the patient is not new, HPI provides expanded problem focus).
Physical Examination: 99214 (the patient is not new; the physical examination is detailed, providing a minimum of two bullets in six or more systems and areas).
Medical Decision Making: 99215 (the evaluation is a broad, excessive understanding of patient’s condition is observed. The examination lasts not less than 40 minutes).
References
Gamache, J., Harrington, A., & Kamangar, N. (2017). Bacterial pneumonia medication. Web.
Pneumonia: Diagnosis. (2017). Web.
2017/18 ICD-10-CM Diagnosis Code J18.9. (n.d.). Web.