HPI
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-thecounter Tylenol for pain.
Tylenol 650 mg, 2 PO as needed.
ALLERGIES/REACTIONS
She is allergic to sulfa drugs that cause a rash. SOCIAL HISTORY
The patient has been widowed for 20 years. She is receiving an annual pension of
$40,000.00 and has some money that she has saved in the bank. She has a high school
diploma and owns her house. Though she has little disposable income, her finances are
essentially stable. She has little knowledge of community resources that are at her
disposal.
She has a primary care provider, whom she sees three to four times every year for a
physical examination. The physician is very busy and does not spend much time with
her. She has insurance but it does not cover all her prescription medications. She relies
on a lot on samples.
She has two grown-up daughters who live in the nearby community. They are both in
their forties and are alive and well. The patient would like her daughters to be more
involved in her life, but she is not sure how to approach them about this. The patient’s
perception of self-efficacy has been declining over the past ten years. She feels that she
could be feeling depressed because she does not get out of the house very often and
this depression is only getting worse with each passing year.
The patient has very low level of day-to-day stress. However, she realizes that her
depressive symptoms may be causing some of her physical symptoms.
She goes to church and has some contacts there. She sees her daughters once a
month. These people are her support system, but she has no one to talk to on a routine
basis.
HABITS
• Diet habits She has a healthy diet and her dietary intake is adequate. The patient has positive
health beliefs and knows that she should be doing more to maintain a healthy lifestyle.
She does not get adequate exercise because of her shortness of breath. She enjoys
visiting her physician. Smoking: She has smoked one pack per day for 40 years.
Alcohol: She denies alcohol use
Substance Use: She denies any street drug use
WORK HABITS
She has always been a hairdresser; is retired now. She goes to church and occasionally
attends some of their functions. Her hobbies include sewing. She is from the United
States and lives in a suburban setting. Crime rate in her locality is low with easy access
to public transportation. There are a variety of community groups, but she is not aware of
these resources.
FAMILY HISTORY
Her two older sisters are alive and well, one with osteoporosis and one with breast
cancer. Her 75-year-old sister was diagnosed with osteoporosis at the age of 55. Her 72year-old sister was diagnosed with breast cancer at 60 years of age.
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