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

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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.

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

What's going on with this man?: "I’ve been feeling run-down"

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

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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Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

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 tetanus 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?

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.

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29 Comment(s)

nursej22, MSN, RN

Specializes in Public Health, TB. Has 36 years experience.

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? 

Hannahbanana, BSN, MSN

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB. Has 51 years experience.

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

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience.

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

 

 

Morgana408

Specializes in Pediatric ICU. Has 17 years experience.

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

Chest CT/CT angio

jb_mmmm, BSN, RN

Specializes in Rehabilitation. Has 2 years experience.

Blood cultures please

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

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.

nursej22, MSN, RN

Specializes in Public Health, TB. Has 36 years experience.

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. 

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience.

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.

RNNPICU, BSN, RN

Specializes in PICU. Has 13 years experience.

I would want and HIV, CBC, CT, CXray 

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

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

handydandy, EMT-B

Specializes in EMT/Urgent Care. Has 6 years experience.

covid shot dates and info 

erniefu, BSN, RN

Has 7 years experience.

Rainbow special for labs. So many differentials with this one.

Blood cultures x2

Blue (INR/PTT, D-dimer)

Yellow (viral and bacterial serology say HIV, STD) to query sepsis.

Green (Lytes, Urea, Creatinine Troponin, CK)

Lavender (CBC plus any addons)

Heparin (Lactate, blood gases)

Chest Xray, Chest CT pulmonary angio to rule out PE, pulmonary edema.

Also we should get an O2 sat (not shown) and start oxygen and ventolin if indicated and per hospital policy.

Curious1997, BSN

Specializes in Psych, Medical. Has 13 years experience.

All the tests already mentioned but also I would want to know specifically what areas he beds down in and frequents. Asbestos? Hx of drug use could mean environmentally compromised areas. Emaciated appearance also points me in that direction. Any factories, toxic emissions? Close to a busy road? Sputum Cytology? R/O cancer.. Chest Xray, CAT Scan? Any pulmonary parasites from strange foods or cooking methods? Tidal volume? Blood gases? Definitely a pulmonary consult! 

Edited by Curious1997

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

First Follow-Up Post

Tests: COVID-19 negative, positive for antibodies

Review of Systems - only abnormal values presented:

  • Skin: Rhynophyma (swollen, red, bumpy nose and cheeks), burst blood vessels on surface of nose, sunburn on face, neck and arms
  • HEENT: small, creamy white lesions are found on the sides of his tongue and the roof of his mouth.
  • Lymph nodes: slight cervical adenopathy
  • Lungs/Thorax: mild axillary lymphadenopathy, bibasilar crackles with auscultation
  • Musculoskeletal: demonstrates difficulty sitting and standing
  • Abdomen: mild to moderate inguinal lymphadenopathy

Chest X-ray: Bilateral diffuse interstitial disease without hilar adenopathy, mild cystic changes, no consolidation, or nodules

Laboratory Test Results (normal values):

  • Na 137 meg/L (135-145)
  • K 4.0 meq/L (3.5-5)
  • Cl 108 (101-112)
  • Mg 2.0 mg/dL (1.8-3)
  • PO4 3.9 mg/dL (2.5-4.5)
  • BUN 10 mg/dL (8-20)
  • Cr 0.8 mg/dL (0.6-1.2)
  • Ca 8.0 mh/dL (8.5-10.5)
  • Hb 10.8 g/dL males (13.6-17.5)
  • Hct 32.2% males (39-49%)
  • Plt 260,000 cu/mm (150,000-450,000)
  • WBC 3.8 x 103/mm3 (4,800- 10,800)
  • Neutros 68% (57-67)
  • Lymphs 18% (25-33)
  • Eos 1.5% (1-4)
  • Monos 11.5% (3-7)
  • Basos 1.5 (0-1)
  • AST 33 IU/L (0-35)
  • ALT 9 IU/L (7-56)
  • Glu fasting 114 mg/dL (60-110)
  • Total Bili 0.6 mg/dL (0.1-1.2)
  • Total Protein 6.5 g/dL (6-8.3)
  • Albumin 2.6 g/dL (3.4-4.7)

Urinalysis: minor dehydration, but otherwise WNL

 

FlorentineRN

Specializes in Public Health. Has 39 years experience.

I’m leaning toward a respiratory infection given his respiratory rate and breath sounds. There is no consolidation which points away from pneumonia.  Lesions in mouth and cachexia could be thrush and general immunocompromise   May be anemia of chronic disease.

Negative COVID test suggests that previous COVID infection may have caused long term pulmonary damage

Differentials
interstitial lung disease of unknown origin (COVID associated, asbestosis? Silicosis?)

R/O TB though lack of cavitary lesions makes this unlikely

 

Admit to inpatient care. Isolate on airborne precautions for now. Continuous O2 monitoring.

RNNPICU, BSN, RN

Specializes in PICU. Has 13 years experience.

I think also a T-cell count and Viral load.  Maybe also see if Segs and Bands could be added in...