Case Scenario

A patient is a 76-year-old male presented in the ED with acute onset shortness of breath. It began
approximately a day before and had progressively worsened without relieving factors reported. He reports
easy fatigability and general body weakness. He prefers to stay on bed and rest except when there is a
need to use the restroom. He denies fever, chills, chest pain and palpitations but coughing is noted without
any sputum production.

Today you were able to meet the patient and did your history taking, ROS, physical examination,
and checked for laboratory examinations. The following were your health data:

Review of Systems
 General: Patient reported to ‘burning hot” 2 days ago. Maximum temperature was 39.7 degrees
Celsius. He experienced chills last night and is feeling very tired. Before the onset of the illness, he
did not notice any unusuality.
 Skin: No noticed rash or skin lesions. His wife reported his skin is warm to touch.
 HEENT: He reports clear nasal discharge that started 4 days ago. He also experienced nasal
congestion and sore throat at the same time that he felt his temperature rising. He is able to
swallow food with very little difficulty. He complained also of intermittent frontal headache for 2
days now.
 Pulmonary: He experienced dyspnea during climbing stairs upon the onset of his cough. No
exertional dyspnea at rest. He reports chest discomfort especially during inspiration. No wheezing
reported. Dry coughing was reported.
 Cardiovascular: No reported exertional dyspnea, orthopnea and chest pain at rest.
 Gastrointestinal: Able to swallow without difficulty but reports decreased appetite. Reports
decreases in appetite.
 Genitourinary: No defecation problems.
 Musculoskeletal: Reports intermittent back pains and abdominal pain every time the client coughs.
 Neurologic: He is slightly drowsy because of the lack of sleep, but is able to coherently answer
questions immediately.
 Psychiatric: Did not report or exhibit any psychiatric problem

Past Medical History

 Social History: tobacco usage (consumes 5 sticks per day for 30 years), drinks alcoholic beverages
on weekends (approximately 3 bottles of beer)
 Family history: Mother is 87 years old and is hypertensive. Father died at age 63 due to coronary
artery disease (CAD).
  Maintenance Medications: Losartan 100 mg/tab 1 tablet once a day, Amlodipine 5mg/tab 1 tablet
once a day. There were other medications prescribed but was unable to purchase due to financial
constraints,
 Allergies to Food and Drugs: Aspirin, no known food allergies
 Other medical conditions: hypertension and diabetes mellitus diagnosed 10 years ago
 Surgical History: No surgical history
 Immunization: Cannot recall immunization received
 Other lifestyle practices: Sleeps for about 5 to 6 hours in a day. His meals are mostly that of fish,
vegetables but sometimes he enjoys dried fish, canned goods and instant noodles especially when
the family cannot afford to buy healthier meal options. He considers walking his granddaughter to
school as exercise (approx 1km). He sometimes works as a carpenter on an on-call basis.

Physical Exam

 General Appearance: Patient stands approximately 6 feet and weighs 50 kilograms, acutely ill-
appearing male. In orthopneic position and is having difficulty breathing
 Initial physical exam reveals temperature 38.7 degrees Celsius, heart rate 120 bpm, respiratory
rate 30 cpm, BP 104/52 mmHg, and O2 saturation 92% on room air.
 HEENT: Normocephalic head, pupils are equal, round, and reactive to light and accommodation,
no scleral icterus, pale palpebral conjunctiva, no abnormal secretions from eyes and ears, no nasal
discharges, palpable submental lymph nodes with reports of tenderness upon palpation, no jugular
vein distention,
 Pulmonary/Chest: Shortness of breath noted with minimal use of accessory muscles, tachypnea
present, bilateral crackles auscultated over bibasal areas, patient barely able to finish a full
sentence due to shortness of breath.
 Cardiovascular: 120 heart rate, regular rhythm, and normal heart sound with no murmur, weak and
thready peripheral pulses, CRT < 2 secs
 Musculoskeletal: cold clammy skin, able to move all extremities, no complaints of joint pains, still
with slight pain reported on lumbar area
 Genitourinary: Able to urinate without difficulty but noticed decreasing amount since yesterday
 Abdominal: bowel sounds are normal. No distension and no tenderness
 Skin: cold and clammy, senile turgor
 Neurologic: Alert, awake, loss of sensation, responds coherently to questions, oriented to time,
place and person