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

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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 101.8^oF
HT 6' 3"
WT 150 lbs
BMI 18.7

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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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About SafetyNurse1968, ADN, 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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