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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"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.”
