- PROMPT 1 DIANA
Subjective
An 89-year old female complains of a “stabbing chest pain” and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that “just seems to hang on.” No other complaints.CC: Stabbing chest pain
QuestionsWhen did the pain start?
Does the pain radiate into any other part of the body?
For how long does the pain last?
What were you doing when the pain started?
What makes the pain better?
What makes the pain worse?
Have you taken any medications? If yes, were they effective?
PMH: None reported
Medications: None taken
Allergies: NKDA
Social history: Patient is a retired chef, currently widowed with two children. Patient does not use any drugs or alcohol, never smoked cigarettes.
Family history: No family medical history reported.
Objective
Physical Exam Elements
- Listen to the lungs with a stethoscope to check for abnormal bubbling or crackling sounds that may suggest pneumonia.
- Measure the patient’s temperature and blood pressure
- Auscultate the patient for abnormalities in breathing sounds
- Assess the patient from head to toe
- AssessmentWorking diagnosis: community-acquired pneumonia- this is the most common type of pneumonia caused by bacteria, fungi, bacteria-like organisms, and viruses. The risk factors include old age, smoking, weak immune system, and chronic disease like chronic obstructive pulmonary disease (Metlay et al., 2019). Symptoms include pain in the chest, shortness of breath, fatigue, and low body temperature.
Differential diagnosis: pulmonary embolism- this is a condition characterized by the blockage of one of the pulmonary arteries in the lungs (Kearon et al., 2019). It is mainly a result of blood clots, which hinder the effective flow of blood into the lungs. Symptoms include pain in the chest, cough, and shortness of breath.
Pertinent positive: Stabbing chest pain
Pertinent negative: A history of upper respiratory infection
Further Testing
CT scan for the chest
Electrocardiogram test
Plan
OTC: Azithromycin 250 mg orally daily for 4 days (Metlay et al., 2019).
Pharmacotherapy: Pain relievers, such as ibuprofen and aspirin to ease discomfort.
Complementary: Warm herbal teas to help in the soothing scratchy throat. Patients may also use herbs like peppermint and eucalyptus to soothing the throat.
Patient Education
- Increase the intake of fluids
- Maintain hand hygiene
- Cover the mouth when coughing
- Take antibiotics as prescribed
- Get adequate rest (Metlay et al., 2019)Follow-up: In one month
