Comprehensive Case Write-up
Please use the attached instructions to complete this assignment. The rubric used to score the assignment is also attached.
Follow the format of https://meded.ucsd.edu/clinicalmed/write.htm. This assignment should be 6-8 pages single-spaced. This is a standardized rubric that will be utilized for all comprehensive write-up grading throughout the program.
Male Health Comprehensive Case Write Up
Student’s Name
Institutional Affiliation
Course
Instructor’s Name
Date
Male Health Comprehensive Case Write Up
ADMISSION NOTE
Chief Concern (CC):
Mr. Johnson is a 40 old man with history of pneumonia, asthma, and high blood pressure. Today Mr. Johnson presents with complaints of 3 days of cough, fever, chills, pain in the chest, nausea, diarrhea, and shortness of breath.
History of Present Illness (HPI):
Mr. Johnson presented with 3 days of cough, fever, chills, pain in the chest, nausea, diarrhea, and shortness of breath. The patient stated that he stated that the symptoms have worsened in the past three days. He says he has not taken any over-the-counter medication because he thought the symptoms would just go away but he is now concerned because of the increasing severity. He says he feels discomfort in the chest. He rated pain in the chest when breathing as 6/10. He woke up in the morning unable to breathe normally and had a high fever, and his cough has been persistent for most of the day. The patient says he takes his asthma and blood pressure drugs are recommended, but does not understand why he developed shortness of breath and fever. He fears it might be something else. The patient has high blood pressure and has been taking Lisinopril 10mg daily. He has a history of asthma and uses two inhalers, Formoterol and Tiotropium every day and doesn’t miss any dosages. He was treated with antibiotics and prednisone a few years ago when he developed pneumonia. Mr. Johnson admitted to having undergone appendectomy in the year 2010 but denied any complications due to that process.
Past Medical History (PMH):
- Hypertension dx 2019
- Pneumonia dx 2019
- Asthma since birth
Past Surgical History (PSH):
- Appendectomy 2010.
- The patient denies any other surgery and stated that he healed completely from the illness. He did not develop any complication.
Medications (MEDS):
The patient is under the following medications for high blood pressure and asthma:
- Lisinopril 10mg daily for management of high blood pressure.
- Formoterol and Tiotropium for management of asthma.
Allergies/Reactions (All/RXNs):
- No history of allergies.
- No Known Drug Allergies
Social History:
Mr. Johnson is a 40-year-old family man. He is married to Angelina who is 35 years now. The couple has three children, but no grandchildren. Their firstborn is now 20 years old, a university student pursuing a bachelor of economics. The second one is a 14-year-old body still in high school. The third born is 5 years old female in elementary school. All three children are healthy without any medical complications. The wife, Angelina, has not developed any chronic disease and is considered healthy. Mr. Johnson’s father died at 79 from heart-related diseases. Her mother is 72 years now and developed high blood pressure, asthma, and arthritis. Mr. Johnson has a car and often walks around shipping and is physically active. He has a few friends in the military and some ordinary people who he can hang out with. He does not like partying but can go out with friends occasionally during the weekends. He likes spending much of his free time with his family.
Smoking:
No history of smoking.
Alcohol:
He admits taking moderate alcohol only during weekends.
Other substance use:
Does not use any other illegal substance.,
Military service:
Mr. Johnson is a marine Corp and has worked in the military since he was 25 years. His father was a retired lieutenant and inspired him to join military.
Family History:
The patient has a mother who is now 72 years old and suffering from high blood pressure, asthma, and arthritis. His father died from coronary heart disease at 79 years old. He has two brothers; the elder brother is 45 years having diabetes. The younger brother is 30 years and healthy. The three children are healthy. His wife is also healthy.
Review of Systems (ROS):
- General: He admitted cough, fever, chills, pain in the chest, nausea, diarrhea, and shortness of breath.
- HENT: Denies oral sores, neck masses, nasal d/c, hearing problems
- Vison: Denies change in vision, eye pain, redness, discharge
- Cardiac: As above
- Pulmonary: As above
- GI: Denies heart burn and swallowing difficulty. Admits abdominal pain and diarrhea, denies constipation
- GU: As per HPI
- Neuro: Denies seizure, weakness, numbness
- Endo: Denies heat/cold intolerance, weight changes, polyuria, polydipsia
- Heme/Onc: Denies unusual bleeding, bruising, clotting
- MSK: Denies join pain, swelling, muscle aches
- Mental Health: Denies anxiety, depression, mood changes,
- Skin/Hair: Denies rashes, non-healing wounds, ulcers, hair loss
PE:
- Vital signs: B/P 110/72, Wt: 154 lbs; Ht: 5′ 6″; BMI 24.9
- General (GEN): looks healthy, upright posture. The patient is alert and oriented in terms of time, place, and people (A&O x3). The patient is well groomed and clean. He maintains eye contact throughout the session.
- HEENT: Mildly icteric, pupils equally round and reactive to light and accommodation. Oropharynx w/o lesions, mucous membranes moist; thyroid not palpable, no adenopathy
- Pulmonary: +dullness to percussion at right base, + crackles 1/2 way up chest bilateral posteriorly.
- Cardio: RRR, +2/6 holosystolic murmur at apex, +S3, no S4, PMI not displaced, no bruits, JVP 8 cm.
- Abdomen: non-distended, nontender, no hepatomegaly, admits abdominal pain.
- Extremities: no edema to sacrum, abdominal wall and scrotum; no clubbing, no cyanosis, no skin breaks distally.
- Pulses: 2+femoral B, 1+ PT/DP B
- Neuro:
- Mental status: alert and appropriate
- Motor: 5/5 all extremities
- Sensory: distal sensation in legs intact to light touch, pin prick. Proprioception toes normal bilaterally. Vibration intact at IP joint bilateral great toes.
- Reflexes: Biceps, triceps, brachioradialis: 2+ B. Patellar, achilles 2+ B; Toes down going
- Gait: Normal.
Labs and Data:
- CXR: Chest X-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia.
- CBC – WBC 25,000/mm3 with + left shift
- SAO2 – 98%
- Sputum tests Gram Stain: 4+ squamous epithelial cells, 4+ segmented neutrophils, no organisms. Culture: No growth at 48 hours
- Pneumococcal Urinary Antigen–Positive
Assessment and Plan:
The patient, Mr. Johnson, is a 40-year-old male who presented with 3 days of cough, fever, chills, pain in the chest, nausea, diarrhea, and shortness of breath. The patient’s symptoms are consistent with pneumonia (Olson & Davis, 2020). The diagnosis is a sufficient explanation of all the symptoms including shortness of breath and chest pains. The patient is predisposed to asthma by his family history. The patient’s mother, who is now 72 years is, has asthma and other chronic illnesses. People who have their family members. Especially parents and siblings, suffering from asthma are more likely to develop the illness.
The shortness of breath is due to swollen airways and fluid and mucus build up in the lungs. The situation makes it hard for the patient to breathe. Similarly, a cough occurs when the air sacs in the lungs are filled with fluids or mucus (Metlay et al., 2019). Chest pain is a common symptom of pneumonia due to the buildup of fluids. These complications are manifested in the pulmonary examination: dullness to percussion at right base, + crackles 1/2 way up chest bilateral posteriorly, and cardio examination: holosystolic murmur at the apex (Olson & Davis, 2020). Other symptoms such as fever, chills, diarrhea, and nausea indicate a possible bacterial infection, which is pneumococcus bacteria.
His treatment included injection of amoxicillin 875 mg and clavulanate 125 mg PO BID. The patient received Panadol to relieve pain and fever. He also received Ventolin to relieve chest pain and shortness of breath (Metlay et al., 2019). He was given loperamide 4 mg orally after the first loose stool, then 2 mg orally after each unformed stool, to treat diarrhea. Dextromethorphan was provided to release the cough. The patient received education regarding pneumonia and its treatment. He was also educated on medication aberrance and preventive measures for pneumonia (Metlay et al., 2019). On the third day of his admission to the hospital Doctor checked him, and his physical examination showed positive results. The patient was discharged on the third day with close follow up to ensure full recovery.
References
Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American journal of respiratory and critical care medicine, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST
Olson, G., & Davis, A. M. (2020). Diagnosis and treatment of adults with community-acquired pneumonia. JAMA, 323(9), 885-886. https://doi.org/10.1001/jama.2019.21118