Pneumonia case study paper
Initials: J.M.
Age: 11 years.
Sex: Male
Race: African American
CC: shortness of breath and cough
Subjective data
HPI: The patient is an 11 year African American boy that has had shortness of breath and productive cough that has occurred for the last two days. The patient complains that the sputum is bloody and is thick green in color. The patient relates that he has shortness of breath while walking and at rest. He complains of fever, and in the process, he used Tylenol to treat the symptoms.
PMHx: the grandmother reports that the boy received all the vaccines as per the schedule stated by the World Health Organization. The patient has no history of admission, a significant illness, or surgeries conducted on him.
Soc Hx: the boy is in grade 4, stays with the grandmother, who is a businesswoman. The grandparents do not smoke cigarettes or take alcohol. In the family, the members usual observe safety measures by wearing safety gears while playing within the home as well as putting on safety belts while using vehicles. The family also enjoys supports system from the boy’s parents who undertake various occupational roles from multiple countries. The boy likes and spends most of his time swimming in the family pool.
Fam Hx: No known history of chronic illness in the family. Both parents and grandparents to the boy are alive with no significant chronic diseases.
Allergies: There is no known food or drug allergy for the patient.
Objective data
Physical examination
GENERAL: Positive for fevers and chills. No weight loss and negative for fatigue.
Integumentary: On assessment, the skin is warm and moist
Respiratory: Thorax is symmetrical with diminished breath sounds, and on auscultation, rales are heard, and expiratory wheezes are heard throughout the thorax (Ball et al., 2015). There are no sounds of rhonchi. Besides, a wet, productive cough is noted during the examination time.
Cardiovascular: The heart has regular sinus rhythm with the heart rate of 82 beats per minute. S1 and S1 sounds are heard which are normal, no murmurs, S3 and S4 are negative. On the assessment of the lower limbs, there is pedal edema noted, and the pulse of dorsalis pedis is bilateral.
HEENT: The head is normocephalic. No discharge from the eye with the pupils reacting to light. Concerning ears, the patient is not able to hear well with the right ear. The patient has a swollen tan. No discharge or bleeding from the canal. No nasal flaring. Full range of motion for the neck and no swollen lymph nodes.
Gastrointestinal: On auscultation of the abdomen, it has normal active bowel sounds in all the four quadrants. No abdominal pain, no nausea, vomiting, or diarrhea.
Genitourinary: No burning on urination
Neurological: No headache or dizziness,
Musculoskeletal: No muscle or joint pain.
Hematologic: No pallor or bleeding.
Lymphatics: No enlarged node.
Psychiatric: Not explored
Allergies: No history of asthma, hives, eczema, or rhinitis.
The radiograph of the chest shows infiltration in the right middle lobe
Vital signs
Blood pressure 129/78mmHg, heart rate 83 beats per minute, temperatures 102.9, respiratory rate 22 breaths per minute, pulse 99, and weight 43kgs.
Differential diagnosis
Pneumonia: The patients come to the health facility with chief complains of productive cough and shortness of breath on exertion. On evaluation, the patient has elevated temperatures, rales, diminished breath sounds, and expiratory wheezes. The symptoms mentioned above identifies community-acquired pneumonia. Besides, Debasis, D., & David C., H. (2009) argues that the chest radiography shows that the patient had infiltration of the right middle lobe of the lung, which another sign of pneumonia.
Myocardial infarction: Again, the patient presents with shortness of breath, which gets worse on exertion and a productive cough. One of the symptoms of myocardial infarction is dyspnea. ECG showed that the patient had a sinus rhythm that is normal with the heart rate of 82 beats per minute. The diagnosis of myocardial infarction would be well-identified if the troponin levels were evaluated.
Pulmonary embolism: According to (Berliner et al, 2016) patients suffering from pulmonary embolism present with dyspnea as its primary symptom. The onset of dyspnea is extremely sudden in pulmonary embolism and taking the history on the way dyspnea appears helps in the diagnosis. Besides, chest angiography, D-Dimer, and evaluation of the lower extremities for pain and swelling would help in confirming the diagnosis.
Congestive heart failure: patients with CHF always present with dyspnea as a common symptom (Berliner et al, 2016). Other symptoms of CHF include, fluid retention, diminished tolerance to exercise or heavy load, and fatigue. Furthermore, the patient presented with rales on chest auscultation that is also consistent with congestive heart failure. Evaluation of brain natriuretic peptide concentration in the blood would help to confirm the diagnosis.
Asthma: The patient presented with shortness of breath and expiratory wheezes, which are symptoms of asthma (Ball et al, 2015). However, the patient also presented with productive cough and elevated temperatures that are not the symptoms of asthma.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The Differential Diagnosis of Dyspnea. Deutsches Aerzteblatt International, 113(49), 834. DOI:10.3238/arztebl.2016.0834
Debasis, D., & David C., H. (2009). Chest X-ray manifestations of pneumonia. Surgery Oxford, (10), 453. DOI:10.1016/j.mpsur.2009.08.006
.
