Breathless, Coughing and Run-down: What's Going On? | Case Study

A new case study in which the patient, a 32-yr-old white male presents to a local free clinic with fatigue, moderate dyspnea, and a persistent and non-productive cough.

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Breathless, Coughing and Run-down: What's Going On? | Case Study

Chief Complaint

"For the past few days I've been feeling run-down. I can't stop coughing and I'm out of breath. It can't be COVID – I already had it a few months ago.”

History of Present Illness

The patient has struggled with homelessness for many years. He visits the free clinic every few months, most recently to be treated for Chlamydia and Gonorrhea after experiencing painful urination and swollen testicles. He states that his symptoms "came on fast.”

General Appearance

Patient is thin and sunburned. He looks more than his stated age, with many wrinkles and burst blood vessels in his nose. His clothing is too large and there is dirt on his pant legs, the creases in his neck and under his fingernails. His hair is long and tangled and in a ponytail. He appears sober and smells of body odor and cigarettes.

Past Medical History

  • RSV at 6 months
  • Treated for tuberculosis for 12 months with isoniazid 5 years ago
  • Perianal ulceration, positive for herpes 4 years ago topically treated with acyclovir and zinc oxide
  • MVA resulting in multiple herniated discs and fractures to spine 3 years ago
  • Tested positive for COVID-19 after experiencing mild fever and cough – he got tested when he lost his sense of smell 6 months ago
  • Chlamydia and Gonorrhea 3 months ago, treated with ceftriaxone and azithromycin.

Family History

No history given

Social History

  • Homosexual, admits to engaging in unprotected intercourse since the age of 18. He lives on and off with his 60 yo aunt "until she kicks me out.”
  • He is unemployed and receives social security disability checks for back pain related to the MVA.
  • He previously had worked for several different gas stations
  • He smokes at least one pack of cigarettes a day "if I can get them.”
  • He has a history of alcohol, cocaine, heroin and methamphetamine abuse.

Immunizations

Had tetorifice shot over 10 years ago but can't recall any others. He does have a COVID-19 vaccination card. "When I found out I could win the lottery, I went right in.”

Medications

None

Allergies

Red rash with Sulfa drugs

Vital Signs

  • BP 133/83 sitting, LA
  • HR 91
  • RR 30
  • T 101.8o F
  • HT 6' 3"
  • WT 150 lbs
  • BMI 18.7

What information do you need for a diagnosis?

What labs do you want?

What other diagnostic tests should we run?

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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Specializes in Public Health, TB.

Full head to toe assessment, including breath sounds and heart tones. How is nutritional intake? Any diarrhea ? 

Tests: Oxygen saturation, CBC, CMP, HIV, chest xray. 

I would want to know more about the TB treatment. Was it for latent or active?  INH would be for latent, but 12 months is longer than usual. Did he actually complete treatment? 

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Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

Nutritional assessment, vit C level, albumin/prealbumin; diff c the CBC; agree c recheck TB treatment and HIV labs. LFTs, CXR & CT.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Agree with above:  Chest CT scan indicated due homeless,  + Smoker, + HIV, HX TB + recent COVID.

Add:

Fe tests, iron indices ((TIBC) check for anemia which would affect oxygenation.

RR= 30, ABG's if pulse Ox< 93.

At 6ft, 150 lb,  BMI 18.7  underweight, add nutrition eval. ? cacexia

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Specializes in Pediatric ICU.

It’s been well covered already, but this is what I’d recommend

Head to toe assessment.  I’d want to know if his cough is productive.  If so-color, amount, and frequency.  I’d want to know his last drink, if he was using drugs-when was the last drugs taken?

What labs do you want? CBC, CRP, CMP, HIV, LFTs

What other diagnostic tests should we run? Chest X-ray.  Possibly chest ct

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Chest CT/CT angio

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Specializes in Rehabilitation.

Blood cultures please

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Specializes in Education, Informatics, Patient Safety.

Thank you everyone for participating! I will answer a few questions now, and post lab values and head to toe tomorrow - just to give more folks time to think on it.

His cough is nonproductive

His TB was latent - he seroconverted - I am not sure why he was on INH for 12 months - it's just what he stated - it is possible his history is unreliable. According to the patient he did finish his TB meds as prescribed.

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Specializes in Public Health, TB.

Maybe because this is my main focus at work, but I am not ready to give up on TB. This could be a drug resistant strain or MAC. 

1) Blood tests for TB (IGRA, QFT, T- spot) are not used to demonstrate adequate treatment. In fact, many people who are treated may remain positive for life. Persons with impaired immune systems may test negative. 

2) I would get sputum for C&S, plus 3 for AFB smear and culture x3 at least 8 hours apart, and get a NAAT ( PCR) on 2 of them. Induce sputum if necessary. 

3) Enlist the help of the local health department to assess for TB. This could take several days.

4) Initiate airborne precautions, if not already done. 

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Specializes in Vents, Telemetry, Home Care, Home infusion.
7 minutes ago, nursej22 said:

Maybe because this is my main focus at work, but I am not ready to give up on TB. This could be a drug resistant strain or MAC. 

1) Blood tests for TB (IGRA, QFT, T- spot) are not used to demonstrate adequate treatment. In fact, many people who are treated may remain positive for life. Persons with impaired immune systems may test negative. 

2) I would get sputum for C&S, plus 3 for AFB smear and culture x3 at least 8 hours apart, and get a NAAT ( PCR) on 2 of them. Induce sputum if necessary. 

3) Enlist the help of the local health department to assess for TB. This could take several days.

4) Initiate airborne precautions, if not already done. 

How could I forget sputum cultures!   Important addition to workup.   Great info.

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Specializes in PICU.

I would want and HIV, CBC, CT, CXray 

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Specializes in Community health.

I think I saw this guy at our FQHC this week. 

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