Unit 3: Unit 3: Respiratory Disorders in Primary Care – Discussion 

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Topics

Topic: Pulmonary Case Presentations

Topic: Pulmonary Case Presentations 

Please select one case presentation below and provide answers to the following;  Three differential diagnoses  Definitive diagnosis  Management plan (include appropriate      treatment/diagnostic tests)  Indications for referral and/or consultations (if      needed)  Health education/lifespan considerations  Schedule a F/U appointment 

Case I: 

50 Y/O CM present with C/O dry cough x 4-5 months with 20 year H/O tobacco use of 1PPD for 20 years. Cough has become progressively worse over the past 2-3 weeks with yellow sputum production. Took OTC cough syrup without relief of symptoms. Afebrile at home. No CP or fatigue except with excessive coughing. No HAs or head injuries. No eye pain or drainage. No ear pain or difficulty hearing. Ocass. nasal drainage of clear mucus. No sore throat or difficulty swallowing. No neck pain or stiffness. Some SOB with excessive coughing. Excessive coughing interferes with ability to perform ADLs at times. No other household members with similar symptoms. 

Temp–97.2

Pulse–94

B/P 140/90

RR- 24

Pulse Ox check– 86% on Room Air

General: Alert, apprehensive but cooperative

SKIN: W/D with rapid recoil

HEENT: Normocephalic. PERRL, sclera clear, Bil. TMs pearly gray. Boggy, pale nasal mucosa. Oropharynx without erythema or exudate 

NECK: Supple without LAD (lymphadenopathy)

HEART: Tachycardia without murmur, gallops or clicks

RESP: Distant lung sounds; positive rales at base with expiratory wheezes 

Case II: (mom is present and is historian) 

3 Y/O Asian male present with 3 day H/O dry cough that’s worse when playing outside near Spring flowers. Took OTC cough suppressant with cough resolved but reoccurred. Afebrile at home. Positive sneezing and itchy eyes at times. Consumes fluid and solid foods without difficulty. Mom reports tiring easily when outside playing with other children in neighborhood. No SOB noted per mom. Remain active and playful. No change in urinary habits with last BM this a.m, of soft brown consistency. 

Temp–98.4

Pulse–104

B/P 80/68

RR- 26

Pulse Ox check– 95%

General: Alert, cooperative without distress.

SKIN: W/D with rapid recoil

HEENT: Normocephalic. PERRL, sclera clear, Bil.TMs pearly gray. Boggy, pale nasal mucosa. O/P without erythema, masses, or lesions. Pink, moist mucous membranes. 

NECK: Supple without LAD

HEART: Regular rate and rhythm (RRR) without murmur

RESP: Expiratory wheezing without retractions or nasal flaring 

ABD: Soft, round, NT with positive BS

Case III: 

J. V., a 24-year-old man, is admitted to the emergency department after a motorcycle accident. He is having trouble in breathing and is very upset. The rescue personnel tell you that his breath sounds are absent on the right side, his chest expands unequally, and that there is tracheal shift toward the left. There is a large contusion on his right rib cage. 

Temp–97.2

Pulse–110

B/P 140/92

RR- 28

Pulse Ox check– 88%

General: Alert & apprehensive

SKIN: Cool & diaphoretic; bluish discoloration to right anterior thorax 

HEENT: Normocephalic; PERRL, sclera clear, Bil.TMs pearly gray. Pink, moist nasal turbinates. O/P without erythema, masses, or lesions. Pink, moist mucous membranes. 

NECK: Tracheal deviation to left with neck vein distention 

HEART: Tachycardia without murmur gallops or thrills

RESP: Tachypneic; BS absent on RUL & RLL with unequal chest expansion; decreased tactile fremitus & hyperresonance on RUL & RLL 

ABD: Soft, round, NT with positive BS

MUSC: MAEW without limitation of ROM; strength 5/5 upper and lower extremities 

NEURO: DTRs 2t; no spasticity or tremors of extremities 

Case IV: 

G. E., a 52-year-old social worker, has been treated for a deep vein thrombosis for 2 days. He calls the nurse to come to his room right away. When the nurse arrives, she sees that he is apprehensive, restless, diaphoretic, and extremely anxious. His pulse oximetry reading is 82% (previously had been 97% on room air), heart rate is 116 beats per minute and blood pressure is 100/56 mm Hg. He is complaining of a sharp chest pain that gets worse when he breathes in and has shortness of breath. 

Temp—101

Pulse–116

B/P 100/56

RR- 26

Pulse Ox check– 82%

General: Alert & apprehensive

SKIN: Cool & diaphoretic

HEENT: Normocephalic; PERRL, sclera clear, Bil.TMs pearly gray. Pink, moist nasal turbinates. O/P without erythema, masses, or lesions. Pink, moist mucous membranes. 

NECK: Supple without LAD

HEART: Tachycardia with S4

RESP: Tachypnea with rales throughout lung fields

ABD: Soft, round, NT with positive BS