Lung Cancer Case Study

was awakened from her sleep by sharp left sided chest pain. The pain worsened with motion and

M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems.

PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia noted. No edema noted in extremities. Patient skin is cool to touch, slightly clammy. EEG shows prolonged QRS wave, with ischemic ST changes and PVCs. Chest radiograph clear.

PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia

Another Consultation Report dated 12/06/2016, indicated that the claimant presented with exacerbation of COPD, acute bronchitis, and pseudomonas aeruginosa. The CT scan of the chest revealed bilateral lower lobe atelectatic changes, fibrosis, and a small 1 cm left lower lobe nodular density. A pulmonary consultation was recommended. His blood pressure was 142/79 mmHg. The physical examination revealed bilateral decreased breath sounds and scattered wheezes. His glucose was 189. DuoNeb, IV Solu-Medrol, and IV antibiotics were prescribed.

Cardiac: Mrs. Elliot states she has experienced chest pain 5-6 times starting three weeks ago when she is Short of breath. The pain she said is on the left side of chest and describes is as sore and uncomfortable. Additionally, the patient has experienced palpitations the past few weeks and is positive for peripheral edema. Denies redness, cyanosis, jaundice, flushing.

Cardiovascular: No chest pain. She has dyspnea on exertion if she walks more than 20 steps. No orthopnea or claudication.

History of Present Illness: Ms. Crouthamel is a very pleasant 76-year-old woman who I saw in April for a COPD and hypoxic respiratory failure. She has had stable symptoms of shortness of breath. She denies any significant cough. She does state that the humid weather can make breathing difficult at times. She remains active by participating in work in her garden on a daily basis. She is on supplemental oxygen 24 hours a day. She does also admit to occasional tobacco use.

No family or self history of lung disease. Denies having ever smoked or living/working conditions that affect breathing. Denies ever having had a TB test. States she does not believe in immunizations and refused them when offered by her physician. States she does not remember when her last chest xray was done. Uses no respiratory medications.

Childhood illnesses include measles, mumps, rubella, and chickenpox. She has fallen many times however, has never broken any bones. Serious traumas include three concussions. Has had many surgeries including tonsils removed, gastric bypass, right hip replacement, 2 bilateral knee surgeries, cataracts removed, back surgery and is waiting for shoulders to be replaced. Reports sinus infections in the spring and fall due to pollen and mold. These symptoms are similar to the ones she is experiencing now. Several years ago, she traveled around the world for 7 months and was in England for the Mad Cow Disease outbreak.

This is 51 year old AAF. Patient is here complaining of several issues as listed. Patietn reports for the past several days she had increased SOB at rest, non-productive cough, adiouble wheezes. Patient denies chest pain, N/V/ D. Patient is a current tobacco user wit 20 pack year hisotyr. Denies use of alcohol or illicit drug use. Denies depressive moods, current pain 3/10.

Respiratory: Patient denies having history of lung diseases such as asthma, emphysema, bronchitis, pneumonia, or tuberculosis. She also denies having chest pain with breathing, wheezing or noise breathing, shortness of breath, hemoptysis, sputum, toxin or pollution exposure. Patient states that she had common cold with some productive cough for about a week last month. Also, patient states that occasionally she experiences shortness of breath when she runs for more than 40 minutes. Patient states that her last chest x-ray was 1 years ago, and the results were negative.

With attention to her pulmonary system, I counted her breaths per minute. She had a rate of 26 which was high and her RN was notified. I inspected for symmetry in breath and observed her chest was broader than it was wide from anterior to posterior. Her skin tone was even and the lesions from her surgery were healing; there was no erythema surrounding

She doesn’t recall any sick contacts, but her husband is a minister, and she mingles with members of his congregation three to four days a week. On physical exam her oral pharynx is slightly erythematous but there is no cobblestoning and her nasal turbinates are neither pale nor inflamed. She has no lymphadenopathy, and her lungs sound clear without any wheezing or crackles.

Breathlessness – Restricts her from walking long distances, it started in 2007 changing after a stopover in Singapore.