Patient Information: A Case Study

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(1) Patient Information:
Katie, 65yrs, F, Caucasian, What insurance do you have?
CC: Cough started a week ago and not getting better.
HPI: Katie is a 65yrs old female came to the clinic along with her son in law, Patrick with c/o cough, which started a week ago and is not getting better. Cough is worse at night, and it wakes her up from her sleep. She also c/o pain on her right side of the chest muscles due to cough. She is feeling very tired and gets easily winded when she takes her daily walks. She has no energy and was unable to go to her curves this week as she usually does. She never felt febrile and she never checked her temperature.
Onset: A week ago.
Location/Radiation: Right side of the chest hurts due to cough.
Duration: During
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Soc Hx: Katie is married and living with her spouse and her married daughter and her family. She takes care of her daughters kids when their parents are at work. Her husband and son in law both smoke, but outside the house. She denies any alcohol or tobacco use. No reported illicit drug use.
CONSTITUTIONAL: Reports feeling tired. (-) fever.
HEENT: (-) Reports of headache or vision changes, (-) nasal congestion, discharge or hoarseness.
NECK/LYMPHATIC: (-) Reports of enlarged lymph nodes
CARDIOVASCULAR: (-) Reports palpitation or dizziness.
RESPIRATORY: Reports cough for a week. Cough is worse at night and it wakes her up from her sleep. Reports easily winded during her daily walks. (-) Reports of wheezing or SOB with rest.
GASTROINTESTINAL: (-) Heart burn or indigestion
Physical exam:
VITAL SIGNS: T: 100.4, BP 130/90, P 80, R 22, even, oxygen saturation: 96%. Height: 62 inches weight: 140 pounds. BMI: 25.6 (Over weight)
CONSTITUTIONAL: Katie is appropriate, cooperative and talkative.
SKIN: Pale and pink. (-) Cyanosis or
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Streptococcus pneumonia is the most common causative organism for CAP. CAP is associated with considerable morbidity, mortality, particularly in elderly patients. Signs and symptoms of CAP includes, fever, rigors, sweating, cough with or without sputum, chest discomfort, and dyspnea. Other nonspecific symptoms include, myalgia, fatigue, anorexia, pain abdomen and headache (Akter et al., 2015).
Pertinent positives: C/o cough, chest discomfort due to cough, fatigue and SOB on exertion and fever. CXR shows dense shadow in the RLL.
Pertinent negatives: None.
Diagnostics: Sputum microscopy and culture, blood chemistry and hematology, blood gases, urinalysis for legionella, blood culture and polymerase chain reaction tests (Akter et al., 2015).
Rx: Antimicrobials are the cornerstone of ACP in any population. Azithromycin 500 mg PO one dose, then 250 mg PO daily for 4 days (Epocrates, 2017). Dispensing quantity: 5. Refill: 0.
Education: Vaccination against pneumonia and influenza as they are the most common cause of CAP (Akter et al., 2015). Adequate hydration and rest. Weight management-

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