Case study for advanced Pharmacology. Health, Medicine Case Study

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Date: June 23, 2020
Chief Complaint: “I have been having fatigue and cough for the past three months. This has been on-and-off for the past two years.”
Health History
Mrs A is a 56-year-old Hispanic woman who lives in the suburbs of Texas, USA. She has been working as a department store cashier for the last twenty years. Mrs A came to the clinic feeling feverish. She had a productive cough accompanied by yellowish, mucoid sputum. Moreover, she feels a sharp pain on her right chest (as pointed by the patient) during inspiration.
Mrs. A states that she started feeling fatigued three months ago after working for straight seven hours. It started as a dry cough which gradually became a productive cough. The colour of the sputum at the time started as whitish mucoid then turned to yellowish-green mucoid sputum. Soon after, Mrs. A incurred an on-and-off fever measuring 37-42 degrees Celsius. Eight days ago, Mrs. A experienced sudden shortness of breath upon walking for a short distance (approximately 10 meters) where she can usually jog for this length at moderate speed without having to catch her breath. The shortness of breath and fatigue was exacerbated by easy activities such as walking around the house and washing the disease, and these are relieved by resting for approximately thirty minutes. Mrs. A remembered of having cold-like symptoms for three days before the occurrence of the fatigue and productive cough. After this, the cough progressed rapidly until the clinic check-up. The night before the consultation, Mrs. A had a high fever measuring 39 degrees Celsius which was partially relieved by taking Paracetamol 500mg thrice at 4-hour intervals. This is also accompanied by chest pain and tightness where she feels a sharp pain on her right chest, especially during inspiration.
Currently, the patient has been taking Losartan 50 mg orally, once daily, as a maintenance medication for five years. She is also taking Vitamin C religiously every day since last year to boost her immune system.
Mrs. A denies any known allergies on food and medications. She was diagnosed with essential hypertension in 2010 and had been taking her medications religiously. She denied any history of hospitalization for the past five years and no history of surgeries in her lifetime. She has not encountered any accidents or incurred injuries. Her latest travel was in December 2018.
Family history reveals that both her parents and two out of three of her siblings had hypertension before the age of 55. Her father died of lung cancer in 2001 while her mother died of cardiac arrest in 2004—all of her children and strong and healthy without any known familial diseases or disorders.
Mrs. A denies any smoking history. However, her husband admitted that she was a smoker for 20 years, and she takes approximately 2-3 sticks of cigarette per day. She stopped smoking three months ago when she noticed that her productive cough does not stop when she continues smoking. She was an alcoholic beverage drinker who only drinks beer and tequila from she was 15 to 30 years old. She stopped drinking after that. However, she sips a glass of red wine once a week before bedtime. She denies illicit drug use in her lifetime. She was vaccinated for dengue fever, pneumonia, and influenza last month.
Mrs. A has been married for 30 years and was blessed with three healthy children. She lives with her husband and youngest daughter in a second-floor apartment. Their living conditions are sustainable, and there are only a few financial problems since her two children are already working. They belong to the lower middle class, and they cannot provide massive financial support for health problems. However, Mrs. A has health insurance.
Mrs. A works at a department store near her house as a cashier. She walks for 15 minutes every day to work and to go home. Her duty starts at 9 am and ends at 5 pm with a 1-hour lunch break every day from Monday to Friday. During Saturdays, Mrs. A goes out with her family for recreation while Sundays are rest days.
Review of Systems
Mrs. A reports of fatigue, mild fever, and mild cough. She sometimes has intense sweating, chills, body malaise, night sweats. She states that “I have gradually lost weight for the past three months and I started to lose my appetite in the past week, which prompted me to consult. Also, I would only like to sleep most of the day.” Mrs. A does not experience blurring of vision, diplopia, eye pain, eye dryness, or any changes in peripheral vision. She states that she had astigmatism and myopia since she was 20 years old. Her last eye exam was done in December 2019. Mrs. A reports hoarseness of voice, sore throat, and frequent coughing for three months with yellow-greenish sputum but denies any inflammation in the sinuses and the neck, dental problems, oral lesions, problems in hearing, or nasal congestion. Her last dental visit was on January 2020.
Her last consultation with her cardiologist was on March 2020, and the results were as follows: normal rhythm, normal ECG, normal 2D-echocardiogram, moderately-high cholesterol, moderately-high triglycerides, normal creatinine, normal AST/ALT, normal blood pressure, and healthy weight. The patient does not experience palpitations or vague chest pain. However, she experiences chest pain on the right during inspiration. The patient denies any history of heart murmurs, edema, and varicose veins. The patient states that she had productive coughs for the past few days and shortness of breath on mild physical activities. Sometimes, she experiences wheezing on expiration. Mrs. A denies any history of lung injuries, respiratory infections for the past year, and hemoptysis. She had a history of gastroesophageal reflux disease since she was 50 years old. However, this is mild, and no maintenance medication is necessary. She denies any history of dysphagia, bloating, ascites, jaundice, edema, nausea, diarrhea, and vomiting for the past six months. However, she a mild loss of appetite when she started to feel fatigued. She denies any history of changes in sensation, weakness in the extremities, and difficulties in mentation for the past six months. The patient also denies the presence of any psychiatric problems. The patient denies any history of anemia for the past year and blood transfusions. She admits to having palpated a moving and enlarged lymph nodes on both sides of her neck.
Physical Examination
General Survey: Mrs. A is ambulatory, alert, coherent, oriented x 3 (place, person, time), dressed appropriately to the weather, ectomorph, well-developed, well-nourished. The patient seems to be in cardiorespiratory distress as manifested by dyspnea on breathing and has a pale appearance.
Vital Signs:
Temp= 37.8 deg C (oral)
BP= 130/90mmHg (patient states that she forgot to take her maintenance)
RR= 25 cpm (the patient walked slowly from their house to the clinic for 20 minutes)
HR= 80 bpm
O2 saturation= 98%
Weight 3 months ago= 130lbs; Weight upon consult= 110lbs; Height= 5’7”; BMI 3 months ago= 20.4 kg/m2 (Normal); Current BMI at present= 17.2 kg/m2 (Underweight)
Skin: The skin is smooth, pale, with normal hair distribution. No wounds and scars.
HEENT: Normal hair distribution on the scalp and face. No scars/wounds on the scalp and head. No tenderness on the frontal and maxillary sinuses. Eyes are symmetrical with no discharge. She has non-icteric but dirty sclerae and pinkish conjunctivae. Good hearing on both ears with no discharges. Intact sense of smell with few mucoid discharges. The upper and lower lips are cyanotic. The patient can swallow food and drink liquids without difficulty. There are no problems during conversation. She has an erythematous mucosa at the back of the throat. Tonsils are not enlarged. Uvula rises upon phonation. There are tender cervical lymph nodes with hypertrophied accessory muscles of respiration. Thyroid gland is not enlarged and rises upon deglutition.
Cardiovascular System: S1 at apex and S2 at the base of the heart. PMI at the 5th (L) ICS, midclavicular line. No S3 and S4. No heaves or thrills. No (B) carotid bruits. HR is at 80bpm with a regular rhythm. Jugular venous pressure is at 9 cmH2O (slightly elevated).
Chest and Lungs: The patient has cachexia, and she is barrel-chested. There is decreased but symmetrical chest expansion. No deformities, scars, and retractions observed. Accessory muscles of breathing are hypertrophied. No masses upon palpation. There are coarse crackles on the bases of the lungs upon inspiration, and variably decreased breath sounds on all lung fields. Other lung lobes have vesicular breath sounds. Equal tactile fremitus and resonant upon percussion on all lung fields. Expiration is longer than inspiration. The patient is negative for egophony and whisper pectoriloquy. There is pain behind the sternum, which is aggravated by coughing.
Abdomen: The abdomen is flabby with no palpable lymphadenopathies. There are no scars or wounds. It is non-tender on all quadrants, tympanitic upon percussion, and normal bowel sounds upon auscultation. No bruits at the abdominal aorta.
Peripheral Vascular/Extremities: There is no edema. Bilateral radial, femoral, and dorsalis pedis pulses are non-bonding with a regular rhythm. The capillary bed refill of bilateral middle and index fingers are approximately 2 seconds. There is clubbing of all the upper extremity digits.
Musculoskeletal: All muscles on bilateral UE and LE are graded 5/5.
Diagnostic Tests
Spirometry Result:
FEV1= 1.75L
FVC= 3L
FEV1/FVC= 58% (moderate)
Chest X-ray: Both lung fields are clear. The heart is not enlarged.
The Potential Differential Diagnosis
1 Chronic Bronchitis
This disease is categorized into a mucoobstructive lung disease which may genetic, environmental, or both in origin. Often, this is the combination of both where risk factors such as exposure pollution and cigarette smoking are rampant. Generally, it is characterized by a chronic productive cough that lasts for three consecutive months in two years. The sputum may vary in color such as yellow, green, clear, or rusty (with blood). This variation may be due to an accompanied bacterial infection. Fever may or may not be present. When present, this may be due to a secondary infection such as tuberculosis or pneumonia. One of the prevailing constitutional symptoms is generalized malaise. Myalgia on the abdominal region and the extremities is rare. However, it is possible. Chest pain may also be felt when coughing. Wheezes may also be heard, especially during exacerbations (Widysanto & Mathew, 2019).
2 Community-Acquired Pneumonia
This disease presents with similar respiratory signs and symptoms with the patient. The most common risk factors include cigarette smoking, a complication from COPD, and human immunodeficiency virus (HIV) infection. The patient’s presentation may include a productive cough greater than two weeks, chest pain, and dyspnea or shortness of breath. Vomiting and nausea may also be present. However, it is only on rare occurrences (Cedars-Sinai, 2020). Etiologic agents can be viral or bacterial in origins such as Haemophilus influenzae, Mycoplasma pneumoniae, and Adenoviruses (Sethi, 2019).
3 Congestive heart failure
Apart from having a long-term history of hypertension, this differential diagnosis has been considered due to the presence of cough, which is one of its symptoms. This cannot rule out in the patient’s case since there were no laboratory and diagnostic tests done. The possibility of having this disease is only minimal. However, as a differential diagnosis should not be neglected since the patient is already 56 years-old with a ten-year history of hypertension.
The clinical diagnosis of CHF can be made through a thorough history-taking and physical examination. The first signs and symptoms include the Complaint of difficulty in breathing at night or paroxysmal nocturnal dyspnea, an increased JVP, presence of S3 murmur, difficulty in tolerating a flat position or orthopnea, crackles, edema of the lower extremities, and cardiomegaly. Cough may also be one of the signs of CHF. This may happen when the fluid from the heart backflows to the lungs resulting in lung irritation. Moreover, the patient also has an increased JVP and heart conditions may aggravate lung conditions and vice-versa (Slostad, Prasad, & Anavekar, 2018).
4 Small Lung Cell Carcinoma
Small lung cell carcinoma, also known as oat cell carcinoma, has been considered secondary to the chronicity of the patient’s illness. Moreover, its most significant risk factor is prolonged cigarette smoking. This is malignant cancer that arises from the peribronchial tree epithelial cells. These cells form the barrier at the lower respiratory tract until the bronchial mucosa. Tumour metastases are typically found in the liver, mediastinal lymph nodes, brain, bones, and adrenal glands (Pietanza et al., 2016).
Frequently, the observed signs and symptoms include cough, breathlessness, weight loss or cachexia, bone pain, body malaise, and in severe cases, neurologic dysfunction. Most of the patients experience these symptoms for about eight to twelve weeks. The etiologic cause of these signs and symptoms is the intrathoracic invasion of the tumor (Pietanza et al., 2016).
Physical examination may reveal dyspnea or shortness of breath. The patient may also use the accessory muscles of respiration to improve lung ventilation. This leads to hypertrophied accessory muscles such as the sternocleidomastoid, scalene, and trapezius. Flaring of the nasal alae may also be observed. Chest examination may reveal findings poin...