Case Study: Raul, Part 2

Medications: Ibuprofen; per patient, he’s been on 2 courses of antibiotics and an albuterol inhaler, which he has with him. 

Allergies: None. 

You learn Raul prefers to be called Ray and has been sick for almost 3 months with symptoms of cough, fatigue, and weight loss. He’s been on antibiotics twice (he doesn’t remember the names of the antibiotics but remembers the first one was 5 days and the second one made him feel “Enfermo en el estómago.” You know enough Spanish to understand it made him sick in his stomach.   

You ask about his fever. Ray says he felt warm when he first got sick and a little sweaty, but it’s been hot outside. The bunk house where he sleeps does not have air conditioning, and the old fan stopped working weeks ago.

You ask him to describe the cough. Ray says that this is what’s been bothering him the most because it makes it hard to work. It occurs “all the time,” sometimes worse at night, definitely worse when he is working in the orchard, especially after it has been sprayed. Occasionally, Ray coughs up some green stuff (mucus). You ask about hemoptysis—Ray and the translator look at you because they do not know what you mean. You rephrase, “Have you coughed up any blood?” Ray says “Si.” The translator continues, “once after I coughed really hard my chest hurt, and I had a bit of blood in my hand.”

You ask more about the chest pain. Ray says (through the translator) that when he had been either coughing hard or working hard, his chest hurt, kind of like if he got punched. Sometimes he gets a sharp pain when he takes a deep breath in or out.  

You complete your HPI by asking him about his weight loss and fatigue. He notes he loses weight every year when he is working the farms— long hours and not so great food—but he has never lost this much weight. He had to put a few more notches in his belt to keep his pants up. As for fatigue, Ray tells you that he feels run down (exhausted) all the time, lacks energy. Although he has had some light duty work in the warehouse, he has not recovered like he thought he should. This worries him. He does not want to risk not staying on as a hire for the rest of this season or being able to come back. He prefers orchard work in the region, and he needs to send money home to his family.  

You complete your ROS and your PE (see for positives and explanations).  

Adult Medical Illnesses: None. 

Childhood Illnesses: Chickenpox, strep throat, fractured right radius as teenager.  

Surgical History: None. 

Trauma: None 

Habits/Risk factors: Occasional beers. 

Preventive Health History: Knows he received vaccinations as a child, otherwise doesn’t see a physician. 

Social History: Migrant farm worker, wife, 3 children and other family live in Navojoa; he returns there after the season in Washington. 

Family History: Unremarkable for medical problems; mother has arthritis in her hands and back as does his father. 

General:  Fevers, chills, night sweats, and weight loss. 

Dermatologic:  No rashes, changes in skin color, masses or lesions, itching, hair loss or changes in hair or nails   

HEENT  

• Head:  No headaches, head injury, dizziness, or lightheadedness. 
• Eyes:  No changes in vision including double vision, eye pain, photophobia.  
• Ears:  No hearing loss, tinnitus, vertigo, otitis.  
• Nose:  No epistaxis, nasal stuffiness, sinus trouble, hay fever.  
• Neck:  No lumps, pain, or neck stiffness. 
• Throat (oropharynx):  No bleeding gums, frequent sore throats or oral ulcers, hoarseness. 

Respiratory:  As per HPI, denies wheezing.  

Cardiovascular:  Chest pain, dyspnea on exertion; no pedal edema, palpitations, or claudication.  

GI:  Nausea; no vomiting, abdominal pain, dysphagia, heartburn, diarrhea, constipation, hepatitis, jaundice, hematemesis, or melena. 

GU:  No dysuria, frequency, urgency, hesitancy or hematuria, or penile discharge. 

MSK:  No pain, swelling, stiffness or locking of joints.  

Psych:  Mild anxiety (situational wondering what’s going on); no depression, sleep disturbance, hallucinations, or suicidal ideations.  

Neuro:  No loss of consciousness, seizures, paralysis, weakness, numbness or involuntary movements  

Hematopoietic:  No prolonged bleeding, easy bruising or known anemia.  

Endocrine:  No polyuria, polydipsia, heat or cold intolerance. 

General appearance: Ray is a  mildly ill appearing Latino male, appears stated age, somewhat pale in appearance and gaunt.   

Vital Signs

• BP 114/72, right arm, sitting.
• P 92 regular.
• RR 20.
• T 100. 
• PaO2 95%. 

Skin: Dry, warm. No jaundice, rashes or skin irregularities.   

HEENT: Normocephalic.   

• Eyes:  Sclerae w/o icterus, conjunctivae clear. PERRLA, EOMs intact. Fundi normal bilaterally w/o papilledema, hemorrhages, or exudates.  
• Ears:  External ear canals clear, TMs with visible light reflex and w/o erythema, bulging, or perforations bilaterally. Hearing grossly intact to conversational voice   
• Nose:  No nasal polyps.  Nasal mucosa/turbinates without lesions or hemorrhages. 
• Oropharynx:  No pharyngeal erythema or exudates. Oral mucous membranes are pale, moist, without lesions. No tonsillar enlargement. Good dentition. 
• Neck: Full range of motion. Thyroid smooth, non-tender, normal in size and consistency and without nodules.  Trachea midline. 

Lymph nodes: No submandibular, cervical, axillary, epitrochlear, or inguinal adenopathy.  

Thorax: AP diameter not increased. No deformities, ribs easily visible  

Lungs: Increased respiratory effort, symmetrical chest expansion, no accessory muscle use. Right lung fields demonstrate, decreased breath sounds and egophany, especially at base, some crackles upper field; tactile fremitus, dullness with percussion throughout entire right lung field.

 
Cardiovascular: Regular rate and rhythm. S1 and S2 normal; no murmurs, gallops, rubs, heaves, or thrills. PMI palpable in the 5th left intercostal space in the midclavicular line and measures approximately [cm].   No JVD [or JVP measured at _ cm above the sternal angle]. Carotids full on palpation without bruits bilaterally.   

Peripheral pulses: Radial, brachial, femoral, posterior tibialis, and dorsalis pedis pulses symmetrical and full with normal upstroke. No carotid, aortic, renal or femoral bruits.   

Abdomen: Soft, scaphoid, without scars or distention. Normal bowel sounds, no abdominal bruits.  No tenderness to superficial or deep palpation, no palpable masses. No rebound tenderness. Liver span [ _ cm] to percussion, with edge palpable at the right costal margin with deep inspiration. Spleen not palpable. 

Back: No kyphoscoliosis; no vertebral or costovertebral angle tenderness to fist percussion.  

Extremities:  Full range of motion; no joint deformities. No clubbing, cyanosis, or edema.  

Neurologic:  CN2–12 grossly wnl; no focal sensory or motor findings upper/lower extremities. 

Mental Status: Alert and oriented x4, cooperative, appropriate.