Primary Health: Cough and Chest Pain


Mrs. C., 62 years of age, is brought to your office by her husband. She states that she hasn’t slept because of a productive cough and slight continuous chest pain. Her chest pain increases with coughing and taking deep breaths. Her past medical history includes type 2 diabetes which is controlled by diet.

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CC: “I have no energy. This feels like the worst cold in my entire life”

Physical exam: Temperature, 101.4°F (states higher in the PM); respiration rate, 26/min; dyspneic on exertion. Shaking chills, skin cool to touch, leg tenderness, crackles, dullness to percussion on the left side.


What additional subjective data do you think the patient will share?

It is necessary to review the patient’s history of health and inquire about the present condition and possible factors that could stimulate a cough: When did a cough start? What is the nutritional status of the patient and does she have a swallowing dysfunction? Does she have any immunodeficiency conditions or lung and heart diseases, poor functional status? Did she recently lose weight? Does she smoke, etc.? (Simonetti, Viasus, Garcia-Vidal, & Carratalà, 2014).

What additional objective data will you be assessing for?

The following clinical manifestations should be additionally checked: (pulmonary) crackling or bubbling noises in the chest, pleural friction rub, wheezing; (cardiovascular) tachycardia; (nervous) mental status; (musculoskeletal) muscle aches, swollen joints, etc.

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What National Guidelines are appropriate to consider?

“IDSA and ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults Patients with Community-Acquired Pneumonia.”

What tests will you order and explain your rationale for your orders?

According to the National Guidelines, “arterial blood gas analysis should be performed in those with an oxygen saturation ≤90% and in those with chronic lung disease” because the patient may show hypoxemia (Gupta et al., 2012, p. e28). Additionally, a “sputum sample for stain and culture (in patients with a productive cough) should be obtained” to identify possible causative agents, e.g., Streptococcus pneumonia, Haemophilus influenza, Staphylococcus aureus, Klebsiella, etc. (Mandell et al., 2007, p. S29). The chest x-ray can help identify cavities, or pulmonary infiltrates (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

Will you be looking for a consult?

No additional consult is required.

What are the medical and nursing diagnoses?

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Medical diagnosis: pneumonia, unspecified organism (J18.9)

Nursing diagnosis: an inflammation of the lung parenchyma characterized by alveolar edema and congestion contributing to poor gas exchange (ineffective airway clearance, acute pain, and impaired gas exchange).

Are there any legal/ethical considerations?

It is observed that the elderly population (65 and more years old) is prone to suffer severe forms of the disease more. Moreover, “mortality in hospitalized CAP patients ranges between 10% and 25%, being particularly high in older adults and in patients with comorbidities” (Simonetti et al., 2014, p. 4). Thus, it can be suggested to consider the higher risk of unfavorable outcomes in the patient due to her advanced age.

What is your plan of care?

Medical: antibiotic treatment (the combination of β-lactams and macrolides should be prescribed for patients with such comorbidities as diabetes) (Gupta et al., 2012).

Nursing: 1) provide some comfort measures (breathing exercises, massage, back rubs, etc.) and administer analgesics to manage acute pain; 2) instruct on how to perform breathing and coughing exercises to promote drainage of secretions and offer supplemental warm fluids to facilitate their mobilization; 3) educate the patient about appropriate hygienic practices (handwashing, disposition of secretions, etc.) to prevent the spread of infection, and its prompt resolution; 4) promote adequate nutrition; 5) educate the patient and her family members about the aspects of the condition, antibiotic therapy, and alleviating measures (Dunphy et al., 2015).

Complementary therapies: Caihu, Shuanghuanglian, Yuxincao or Qinkailing injections can help alleviate the respiratory symptoms and improve the immune function (Wu, Bian, Abudu, Adams, & Ko, 2014).

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Are there any Healthy People 2020 objectives that you should consider?

Environmental health: “Promote health for all through a healthy environment” (US Department of Health and Human Services, 2018, para. 1).

Respiratory diseases: “Promote respiratory health through better prevention, detection, treatment, and education efforts” (DHHS, 2018, para. 1).

Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting her and the family involved in the care to reach optimal health?

It is essential to ensure the continuity of care (disease management and information flow) involving both physicians and nurses as it largely defines the quality of care and patient satisfaction (Price & Lau, 2013). It can be useful to provide the patient and her family with the information about available sources of community support (e.g., aging services, local Care Circle programs, etc.) as they may be used to derive psycho-emotional comfort.


Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: The art and science of advanced practice nursing (4th ed). Philadelphia, PA: F.A. Davis

Gupta, D., Agarwal, R., Aggarwal, A. N., Singh, N., Mishra, N., Khilnani, G. C., … for the Pneumonia Guidelines Working Group. (2012). Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India: Official Organ of Indian Chest Society, 29(Suppl 2), S27–S62.

Mandell, L. A., Wunderink, R.G., Anzueto, A., Barlett, J., G., Campbell, D., Dean, N. C… Whitney, C. G. (2007). Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. IDSA/ATS Guidelines for CAP in Adults, 44(Suppl2), S27-S72.

Price, M., & Lau, F. Y. (2013). Provider connectedness and communication patterns: extending continuity of care in the context of the circle of care. BMC Health Services Research, 13(1), 1-10.

Simonetti, A. F., Viasus, D., Garcia-Vidal, C., & Carratalà, J. (2014). Management of community-acquired pneumonia in older adults. Therapeutic Advances in Infectious Disease, 2(1), 3–16.

US Department of Health and Human Services. (2018). 2020 topics and objectives. Web.

Wu, T., Bian, Z., Abudu, M., Adams, D., & Ko, S. (2014). Complementary and alternative medicine for respiratory tract infectious diseases: Prevention and treatments. Evidence-Based Complementary and Alternative Medicine, 1-2.

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