APA format 3 peer review references due 10/13/18 at 2pm EST  Patient Initials: __JH_____                Age: __60_____                                 Gender: ____M___ Subjective Data: Chief Complaint: Case #3 “I have a cough that’s getting worse.” (Laureate Education, 2012). HPI: Mr. Hendricks is a 60 year-year old Caucasian male who presents today complaining of a cough that is progressively getting worse; more frequent over the past three days. He states that his cough is accompanied by expectoration of thick green secretions accompanied by some blood at times. He has associated symptoms of shortness of breath that is aggravated when walking and nothing seems to help. Patient also states that he had difficulty trying to fall asleep last night because he felt like he was getting a fever and had intermittent chills and sweats and took Tylenol. He states “I have never felt like this before and would like to know what’s going.” Medications: over the counter Tylenol 650mg po at nights. Allergies: No known drug or food allergies. No seasonal allergies. Past Medical History: No medical history provided. Past Surgical History: No surgical history provided. Immunization history: Up to date with immunizations. Influenza shot received September 2018. Pneumococcal vaccine received October 2018. Personal/Social History: Patient denies smoking, drinks wine socially, exercise with brisk walking three times weekly and tries to eat a balanced diet. He has a master’s degree in finance and works as an accountant at an accounting firm. He is a safe driver who drives to work daily and always wears seatbelt. He lives with his wife who is a homemaker who helps baby sit twin granddaughters. Patient denies history of recent travel to foreign country within the three months. Review of Systems General: productive cough with green phlegm and blood at times; shortness of breath, chills, night sweats, fever and restlessness. HEENT: Patient denies head or nasal congestion, headache, nasal discharge, dizziness, vertigo. Patient states productive cough with green-colored sometimes bloody phlegm. Cardiovascular: Patient denies palpations. Has some chest tightness. Respiratory: Patient states that he has SOB that worsens with walking. Has productive cough with green-colored sputum and occasional hemoptysis. Patient states that he hears whistling noises when he breathes. Objective Data: Physical exam: General: Mr. Hendricks is a 60 year old Caucasian male and a good historian who is relatively healthy and has good hygiene. Alert and oriented x 3, looks age appropriate with normal facial expression and appropriate behavior. He coughed a few times during exam and appears to be in some respiratory distress with shortness of breath. Vital signs: Ht. 5’9”, Wt. 210 lbs; BMI= 30, blood pressure 128/70, pulse of 82, respirations of 20 and labored, temperature of 100.9 and O2 saturation on room air of 89%. HEENT: No headache or head masses. No lesio ...

1. APA format 3 peer review references due 10/13/18 at 2pm EST
Patient Initials: __JH_____ Age:
__60_____ Gender: ____M___
Subjective Data:
Chief Complaint:
Case #3 “I have a cough that’s getting worse.” (Laureate
Education, 2012).
HPI:
Mr. Hendricks is a 60 year-year old Caucasian male who
presents today complaining of a cough that is progressively
getting worse; more frequent over the past three days. He states
that his cough is accompanied by expectoration of thick green
secretions accompanied by some blood at times. He has
associated symptoms of shortness of breath that is aggravated
when walking and nothing seems to help. Patient also states that
he had difficulty trying to fall asleep last night because he felt
like he was getting a fever and had intermittent chills and
sweats and took Tylenol. He states “I have never felt like this
before and would like to know what’s going.”
Medications:
over the counter Tylenol 650mg po at nights.
Allergies:
No known drug or food allergies. No seasonal allergies.
Past Medical History:
No medical history provided.
Past Surgical History:
No surgical history provided.

2. Immunization history:
Up to date with immunizations. Influenza shot received
September 2018. Pneumococcal vaccine received October 2018.
Personal/Social History:
Patient denies smoking, drinks wine socially, exercise with
brisk walking three times weekly and tries to eat a balanced
diet. He has a master’s degree in finance and works as an
accountant at an accounting firm. He is a safe driver who drives
to work daily and always wears seatbelt. He lives with his wife
who is a homemaker who helps baby sit twin granddaughters.
Patient denies history of recent travel to foreign country within
the three months.
Review of Systems
General:
productive cough with green phlegm and blood at times;
shortness of breath, chills, night sweats, fever and restlessness.
HEENT:
Patient denies head or nasal congestion, headache, nasal
discharge, dizziness, vertigo. Patient states productive cough
with green-colored sometimes bloody phlegm.
Cardiovascular:
Patient denies palpations. Has some chest tightness.
Respiratory:
Patient states that he has SOB that worsens with walking. Has
productive cough with green-colored sputum and occasional
hemoptysis. Patient states that he hears whistling noises when
he breathes.
Objective Data:

3. Physical exam:
General:
Mr. Hendricks is a 60 year old Caucasian male and a good
historian who is relatively healthy and has good hygiene. Alert
and oriented x 3, looks age appropriate with normal facial
expression and appropriate behavior. He coughed a few times
during exam and appears to be in some respiratory distress with
shortness of breath.
Vital signs:
Ht. 5’9”, Wt. 210 lbs; BMI= 30, blood pressure 128/70, pulse
of 82, respirations of 20 and labored, temperature of 100.9 and
O2 saturation on room air of 89%.
HEENT:
No headache or head masses. No lesions. Wears glasses. Pupils
equal and reactive to light; ears symmetrical, no tenderness or
discharge. No frontal or maxillary sinus tenderness. No
discharge from nose and mucosa pink and moist. Wears partial
upper dentures. Throat appears red. Good hygiene.
Neck:
No masses, full range of motion. Thyroid size normal.
Integumentary:
Warm and most
Respiratory:
Thorax symmetrical with diminished breath sounds. B/L rales
and expiratory wheezes throughout. Wet productive cough.
Cardiovascular:
regular heart rate with good S1 and S2 heart sounds. No S3, S4
or murmur.

4. Gastrointestinal:
abdomen protuberant. Normoactive bowel sounds in all four
quadrants.
Peripheral vascular:
No peripheral edema. 2+ dorsalis pedis pulses palpated
bilaterally.
ASSESSMENT:
Lab Tests and Results:
CBC: Blood tests are used to confirm an infection and to try to
identify the type of organism causing the infection (Mayo
Clinic, 2018.)
Sputum culture: is taken after a deep cough and analyzed to
help pinpoint the cause of the infection (Mayo Clinic, 2018).
O2 saturation: decreased oxygen saturation indications indicates
hypoxemia. Normal range should be 95-100% on RA (Mayo
Clinic. 2018).
Diagnostics:
Chest X-ray: helps your doctor diagnose pneumonia and
determine the extent and location of the infection (Mayo Clinic,
2018).
Differential Diagnoses:

5. Bacterial pneumonia: is an infection of the air sacs in one or
both lungs which may fill with fluid or pus, causing cough with
phlegm or pus, fever, chills, and difficulty breathing, dullness
to percussion, decreased breath sound, fatigue. It is most
commonly caused by
Streptococcus pneumoniae
(Mayo Clinic, 2018). Since the patient appears to have most of
these symptoms, this is a great possibility.
Acute bronchitis: Acute bronchitis, often called a “chest cold,”
is the most common type of bronchitis. It occurs when the
airways of the lungs swell and produce mucus which makes one
cough. It is caused by a virus and often occurs after an upper
respiratory infection. Symptoms include sore throat, soreness in
the chest, fever, coughing with or without mucus production,
fatigue, mild headaches and watery eyes (CDC, 2017b). This
can also be a possibility based on the patient’s symptoms.
Asthma exacerbation: Asthma is a disease that affects your
lungs. It causes repeated episodes of wheezing, breathlessness,
chest tightness, and nighttime or early morning coughing.
Asthma can be controlled by taking medicine and avoiding the
triggers that can cause an attack (CDC, 2017a). This can also be
a possibility based on the patient’s symptoms.
Bronchiectasis exacerbation: Bronchiectasis is a condition in
which the airways (called bronchial tubes) that branch from the
trachea into each lung become widened and inflamed. Such
damage limits the ability of the airways to clear bacteria and
mucus from the lungs, resulting in sputum production, cough,
and shortness of breath. Bronchiectasis can be congenital or
acquired as a result of an infection. Symptoms include cough,
shortness of breath, wheezing, weight loss, fatigue and chronic
sinusitis (Mount Sinai, 2018). Based on these symptoms, this
can be a possibility for patient diagnosis.

6. COPD exacerbation: chronic obstructive pulmonary disease
(COPD) experiences long-term and progressive damage to their
lungs. This affects air flow to the lungs. Symptoms include
rapid shallow breathing, increasing amounts of mucus, which is
often yellow, green, tan, or even blood-tinged, experiencing
shortness of breath at rest or with minimal activity, such as
walking from one room to another and wheezing more than
usual (Healthline.com, 2018). Based on patient symptoms, this
can also be a possibility for the patient condition.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015). Seidel's guide to
physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Centers for Disease Control and Prevention (2017a). Asthma.
Retrieved October 9, 2018 from:
https://www.cdc.gov/asthma/
Centers for Disease Control and Prevention (2017b). Bronchitis.
Retrieved October 9, 2018
from: https://www.cdc.gov/antibiotic-use/community/for-
patients/common-illnesses/bronchitis.html
Healthline.com (2018). COPD Exacerbation. Retrieved October
9, 2018 from:
https://www.healthline.com/health/copd/exacerbation-
symptoms-and-warning-signs

7. Laureate Education. (Producer). (2012). Advanced health
assessment and diagnostic reasoning.
Baltimore, MD: Author.
Mayo Clinic (2018). Pneumonia. Retrieved October 9, 2018
from:
https://www.mayoclinic.org/diseases-
conditions/pneumonia/symptoms-causes/syc-20354204
Mount Sinai (2018). What is Bronchiectasis? Retrieved October
9, 2018 from:
http://nationaljewish.mountsinai.org/conditions-we-
treat/bronchiectasis-and-ntm/