After conducting an extensive review of the case of the 65-year-old, female Caucasian who was complaining of a two-week cough that eventually causes other complications the following insights had been learned:
- Cough lasting for two-weeks should be tested for the possibility of tuberculosis or other pulmonary/respiratory illness.
- Abnormal CBC results especially high WBC is indicative of existing infection.
- Fever would signal the infection.
- In the case of the patient, this is validated by the white material on the buccal mucosa. This is indicative of infection caused by a fungi thereby causing the fever.
- While patient reports a healthy diet, patient’s BMI suggests that she is borderline obese with BMI at 30.2. The diagnosis of obesity is because weight should be commensurate to the individual’s height.
- Patient was diagnosed with ICD-10: 012.31 - Tuberculous laryngitis, bacteriological or histological examination not done. This diagnosis was made because of the associated symptoms of cough lasting for 2 weeks prior to hospital admission, breathing difficulty, decreased breath sounds, dull to percussion right lower lobe that ends with expiratory wheeze in right lower lobe, and increased anterior-posterior diameter to chest wall
- Patient was diagnosed with ICD-10, 27.800 – Obesity, unspecified. The diagnosis was made after computing for patient’s BMI. Result revealed 30.2 BMI warranting a borderline obese classification. Patient was also diagnosed with ICD-10, V790 - Screening for depression after verbalizing that she is experiencing depression that has been causing her physical symptoms.
- The first intervention proposed was behavior modification because of high-risk behavior like smoking one pack of cigarette a day. In addition, patient also practice a sedentary lifestyle.
- Patient is also advised to undergo health screening to validate all the diagnosis made regarding her physical signs and symptoms. Patient’s refusal to get screened could potentially aggravate her condition instead of addressing it earlier.
- Patient’s family is also advised to get involved in the life of the patient after patient expressed experiencing depression.
Edwards, J., 2014. Talk Therapies. [Online] Available at: http://www.mentalhealth.org.uk/help-information/mental-health-a-z/T/talking-therapies/
Janz, N. & Becker, M., 1984. The Health Belief Model: A Decade Later. Health Education Behavior, 11(1), pp. 1-47.