Concern for pneumonia or other lower respiratory tract infection

Patient is 69-year-old female who states that since June 1 she has been having some what she calls a lung pain that seems to cause a kind of sharp stabbing pain in her back and feels like it is in the lungs and not the chest. She states that happens intermittently, but makes it hard for her to breathe. She also has a dry cough that has been chronic for many years, but has progressively getting worse lately. Because of these symptoms, she did go to the ER. She is worried that it could be heart attack or pneumonia. She does state that it mostly feels like her lungs are filling with fluid and she cannot take a deep breath. She does not have a history of asthma, COPD, and has not ever been a smoker, but was around a lot of secondhand smoke as a child. She was given steroids and a Medrol Dosepak in the ER and a ProAir albuterol inhaler to use. She thinks the ProAir does help some and feels that the steroids have helped resolve some of the trouble breathing as well. She continues to be concerned now and feels that she may have an infection or something else. They did discuss with her in the ER that they thought possibly it was due to allergies, so she came to see us.

She currently complains of nasal symptoms of sneezing, nose rubbing, and nasal stuffiness. She does have annual problems with nasal congestion, but mostly this nonproductive cough is what bothers her and she is not sure if it is from a postnasal drip or from the lung. She has been told in the past that it was allergies. She did undergo an allergy evaluation two years and she was moderately allergic there, but has never tried much allergy medication in the past. She denies any sinus infections, nasal polyps, TMJ, frequent headaches, aspirin induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis that is moderate in severity. She currently is using a methylprednisolone Dosepak and ProAir, but does not currently use nasal sprays or antihistamines.

She denies frequent ear infection, dizziness or lightheadedness. She does have slight hearing impairment and tinnitus.

She does have eye itching, redness, and tearing. She denies dryness, burning, light hurting her eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation. This occurs some of the time.

She does have some mild-to-moderate wheezing episodes currently associated with cough and tightness in chest. She did go to the emergency room for this where they gave her methylprednisolone and ProAir HFA. She currently complains of frequent coughing spells and shortness of breath with exercise. She denies recurrent night cough, coughing up mucus, blood in mucus, coughing on exertion, coughing when wheezing, coughing with laughing, lying down, and talking on the phone. She did not have a chest x-ray performed when she went to the ER.

She denies a history of eczema or allergic skin problems. when she was 57 years old shown to be positive for grasses, weeds, molds, and dust. She has never had allergy immunotherapy.

ASSESSMENT:
1. Chronic cough.
2. Restrictive lung disease versus mild persistent asthma versus ACOS.
3. Possible allergic rhinitis versus mixed rhinitis.
4. Allergic conjunctivitis.
5. Concern for pneumonia or other lower respiratory tract infection.

PLAN:
1. At this time, I did discuss with that she did have what appears restrictive pattern on her spirometry today. I do want her to pursue a chest x-ray to rule out any other etiology of this and she would like to do so as well.
2. I did give her QVAR inhaler 80 mcg two puffs twice a day to see if would help open her lungs up if there is some inflammation involved and also to keep using the ProAir as needed if she feels that chest tightness or shortness breath.
3. I do want to also pursue a CBC, CMP, ESR, and CRP to make sure that her blood work is normal.
4. I am also concerned she may be having a type of pleuritis due to her sharp pain she is having in her lungs, but did tell her to try using Aleve twice a day see if that would help clear some of those sharp pains. We will follow up in two weeks and see if any of these interventions have helped and go over her chest x-ray and lab results.

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