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80 Year Old Male with Hemoptysis

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by

Albert John Bromeo

on 9 March 2015

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Transcript of 80 Year Old Male with Hemoptysis


History
Approach to Diagnosis
Primary Diagnostic Evaluation
Sputum Day 1
Primary Working Impression
Highly Considering Neoplasm of the Lung
vs Pulmonary Tuberculosis V
Pneumonia in the Elderly
Chronic Obstructive Pulmonary Disease Suspect
Seborrheic Dermatitis
General Appearance
awake, alert, oriented, coherent, not in cardiorespiratory distress
Physical Exam
General Data
Greggy Castor
80 year old male Filipino
born and currently residing in Bailen, Cavite
Roman Catholic
retired
Chief Complaint
hemoptysis
History of Present
experienced cough, nonproductive, occurring intermittently throughout the day, with no other associated symptoms
self-medicated with herbal concoctions to no effect
no medical advice sought
Illness
3 YEARS PRIOR
persistence of cough
development of gradual weight loss, exertional dyspnea, easy fatigability, and productive cough
consulted at Rural Health Unit, allegedly normal findings
SUCCEEDING YEARS
coughing of about 3 tablespoons of fresh bright red blood
anxiety about hemoptysis prompted home consult
3 DAYS PRIOR
Review of Systems
(+) pruritus on scalp area
(−) fever, malaise, night sweats
(−) head and neck abnormalities
(−) chest pain, orthopnea, PND
(−) abdominal pain, vomiting, bowel
movement changes, GI bleeding
(−) dysuria, polyuria, polydipsia,
hematuria, LUTS
(−) psychiatric symptoms
(−) neurologic symptoms
Past Medical History
no other diagnosed comorbid illnesses
has annual health examinations which never returned with negative results
no known food and drug allergies
Family Medical History
mother and sister died of breast cancer
father died of stroke
youngest sibling has hypertension
no other heritable illnesses in the family
Personal & Social History
married for 63 years with 7 children
primary school graduate
formerly worked as a farmer
120 pack year smoker (2 packs per day since 20s)
occasional alcoholic beverage drinker
denies illicit drug use
Vitals
120/90 mmHg
92 beats/min
22 breaths/min
36.7 C
Anthropometrics
Height of 171 cm

Weight of 75 kg

BMI 25.65 kg/m2
Head & Neck
anicteric sclerae
pink palpebral conjunctivae
no head and neck masses
no cervical lymphadenopathy
no neck vein distention
no tonsillar congestion
Chest
no chest deformities
equal chest expansion
no dullness/hyperresonance on percussion
clear breath sounds on all lung fields
no vocal/tacile fremiti
Heart
adynamic precordium
distinct S1 & S2
normal rate & regular rhythm
apex beat at 5th ICS L MCL
no murmurs
no extra heart sounds
Abdomen
soft and flat
normoactive bowel sounds
no tenderness
no palpable masses
liver span and edge normal
Traube's space intact
no ascites
Skin
alopecia on scalp
fair skin with good skin turgor
no skin lesions
no nail deformities
Extremities
no deformities
no muscle atrophy
full passive and active range of motion on all joints
Neurologic
intact higher cortical function
intact cranial nerves
no sensorimotor deficits
normal deep tendon reflexes
no cerebellar signs
supple neck
Pulmonary Tuberculosis
Neoplasms of the Lung
Community-Acquired Pneumonia
Direct Inhalational Injury
Pulmonary Vascular Conditions
no AFB seen
Sputum Day 2
no AFB seen
80 Year Old Male with
Hemoptysis
A Family Case Presentation
Bromeo
Autea
Berba, CM
Family Life Cycle
Family in Later Years
couple now live alone but family is just nearby
Greggy and Macy act as peers rather than parents
presence of grandchildren make life more lively
Family APGAR
SCREEM
Genogram
Family Map
Family Timeline
1934 Greggy is born
1951 Greggy meets Macaria and marries her
1955 Conrad is born, starting a series of
births to eventually complete 7 kids
1975 Conrad marries and moves out,
starting the launch of children
2002 the last of the kids, Cynthia, migrates
to the USA, leaving an empty nest
Illness Trajectory
Reaction to Diagnosis
impact of diagnosis to patient and family
need for educational counseling due to uncertainty of diagnosis
family meetings
Catharsis
Greggy admits that he does not know what cancer and tuberculosis means; he just knows that they are both deadly
he does not want to undergo exhaustive diagnostic procedures; he just wants symptomatic treatment
Lerma is more knowledgable, but concedes to Greggy's decision
Education
thorough discussion about cancer and tuberculosis
explanation of need for further diagnostic testing due to difference in treatment
prognosis of each illness explained
Action
consultation with senior - treat initially as CAP and reevaluate after antibiotic treatment
still for further diagnostic work-up
Action Plan for Greggy
Diagnostics
chest PA with AL after 2 weeks
CBC
FBS
spirometry
Therapeutics
co-amoxiclav 625 mg/tab 1 tab BID x 7 days
tranexamic acid 500 mg/tab 1 tab BID x 7 days
General Wellness
low fat diet, exercise as tolerated
mild shampoo when bathing
continue smoking cessation
vaccination
avoid stressors
Action Plan for Macy
Diagnostics
K, creatinine
12L ECG
FBS, lipid profile
urinalysis
Therapeutics
amlodipine 5 mg/tab 1 tab OD
General Wellness
DASH diet, exercise as tolerated
maintain BP diary
daily hygiene
vaccination
avoid stressors
Case
Presentation
Family
Analysis
CEA
Full transcript