A 65-year-old Caucasian female presents with a chief complaint of cough for two weeks. She has been complaining of dry cough since the past two weeks and low grade fever that started two days ago, and was as high as 101 orally. She has had a decreased appetite but no nausea and vomiting. The cough occurs during the night and she needs to sit up in a chair to be able to breathe easier. The cough is mainly dry, rarely productive.
She had been prescribed inhalers in the past; they have been helpful but she does not use them on a routine basis. She has been prescribed antibiotics in the past as well and that seems to help when she is acutely ill. She has been suffering from shortness of breath for the past two weeks following any kind of activity mainly because of the dry cough. She thinks it?s possible that there?s some problem with her ?heart.? She is also complaining of slight sore throat, especially in the morning and feels she may have lung cancer.
The patient?s symptoms have been worsening over the past two days.
She has had similar episodes in the past. The last was three months ago when she had to go to the emergency room and they told her that she needed to be hospitalized. She declined hospitalization at that time and was treated and released. She says they gave her antibiotics and an inhaler before discharging her. She mentioned that though it took some time to feel better, there was gradual improvement in her condition following that treatment. According to her, this is the worst episode that she can remember. She?s very concerned today that she could have pneumonia and might require hospitalization.
She is seeking medical attention today because of the fever and prolonged nature of her illness.
PMH
Though she has been treated for this problem in the past with antibiotics and inhalers, she has not been hospitalized. The patient had a chest investigation the last time she had this problem. She states that she did not have pneumonia but did have ?emphysema.? The healthcare professionals wanted to do pulmonary function tests, but she declined.
X-ray report:
X-ray results: Hyperinflation of both lungs with an increased AP diameter. There is evidence of emphysema. .
She states that she had asthma as a child and is a cigarette smoker. She also had a hysterectomy way back in 1970s. Besides these, she has no known chronic medical problems.
ROS
Shortness of breath with activity. No diaphoresis. She has had a fever. No nausea and vomiting. Denies chest pressure sensation with physical activity. No palpitations.
MEDICATIONS
The patient does not take any prescription medicines. She takes occasional over-the- counter Tylenol for pain.
Tylenol 650 mg, 2 PO as needed.
ALLERGIES/REACTIONS
She is allergic to sulfa drugs that
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