Pulmonary Case Study – Pneumonia

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Running head: ​​ PULMONARY CASE STUDY

 

 

 

 

 

 

 

Pulmonary Case Study

David Cox

Maryville University

Pulmonary Case Study

Basic Information

 

Site:​​ Floor

Service:​​ Hospitalist

Date of Admission:​​ 9/1/18

Patient Initials:​​ XY

 

Subjective History

 

CC: ​​ “Trouble breathing​​ this morning

 

HPI

 

XY is an 84 y/o M with a PMH of HTN, BPH and seasonal allergies,​​ presenting to the ED​​ today​​ for trouble breathing. ​​ He states​​ that yesterday he developed a productive cough with yellow sputum. ​​ This morning he states that he developed shortness of breath and asked his wife to drive him to the ED. ​​ He also reports​​ feeling​​ fatigued. ​​ In the ED his O2 saturation​​ was​​ noted to be 89% on RA and his temperature​​ was​​ 99.3.

 

Additional questions:

  • Have you taken anything for your cough?

  • Do you have any associated symptoms with your shortness of breath?

  • Do you have any history of COPD?

  • Does anything make your SOB worse?

  • Does anything improve your SOB?

  • Have you been around anyone sick recently?

  • Any recent travel?

  • How long have you had an elevated temperature?

  • Do you have any night sweats?

 

PMHx:​​ 

  • HTN

  • Seasonal allergies

  • BPH

 

Additional Assessment: ​​ Inquire if patient takes aspirin for a medical condition other than HTN.

 

Current Meds:​​ 

  • metoprolol 25 mg po qd

  • aspirin 81 mg po qd

  • claritin prn

 

Additional Assessment: ​​ 

  • Clarify Claritin dosage and frequency. ​​ 

  • Inquire why​​ patient is​​ taking ASA. ​​ 

  • Ask about any possible recent antibiotic usage.

 

Med Allergies:

  • NKDA

 

Additional Assessment: ​​ Verify that the patient has no drug allergies, and if so, what reactions/severity were experienced.

 

PSHx:

  • Cataract removal last year

  • Cholecystectomy 20 years ago

 

Additional Assessment: ​​ Verify this is a thorough PSH and that the patient has not had any other surgical procedures.

 

Social hx:​​ 

  • Tobacco:​​ denies.

  • Alcohol: ​​​​ reports drinks once per week

  • Illicit drug use:​​ denies.

 

Additional Assessment: ​​ 

  • Inquire about previous cigarette usage. ​​ 

  • Ask how​​ many drink equivalents​​ patient​​ has when he drinks.

 

Family hx: ​​ Non-contributory

 

Additional Assessment: ​​ Inquire if patient is up to date on influenza and pneumonia vaccines.

 

ROS

  • CONSTITUTIONAL: ​​ FATIGUE

  • Eyes

  • ENT

  • RESPIRATORY: ​​ REPORTS COUGH, SHORTNESS OF BREATH, TACHYPNEA

  • Cardiovascular

  • GI

  • GU

  • Musculoskeletal

  • Neuro

  • Psych

 

Additional questions:

  • Any fevers?

  • Any chills?

  • Any chest pain?

  • Any myalgias?

  • Any malaise?

  • Any nausea, vomiting, or diarrhea?

  • Any dizziness?

  • Any syncope?

  • Any palpitations?

 

Objective Assessment

 

Vitals:​​ B/P 124/80, T:​​ 99.3F, HR: 96, RR 22, SpO2: 89% RA

 

Bedside monitoring data: none available

 

Critical care support settings: ​​ none​​ available

 

Physical exam:

  • Constitutional: ​​ answers questions without difficulty

  • Eyes

  • ENMT

  • Neck

  • Cardiovascular: ​​ RRR, S1, S2, borderline tachycardia

  • RESPIRATORY: ​​​​ MILD TACHYPNEA,​​ lungs CTA bilaterally on RA, even respirations

  • GI

  • Integumentary

  • Neurologic: ​​ A&Ox3

  • Psych

 

Additional​​ Assessments:

  • Any vocal or tactile fremitus, egophony, or bronchophony?

  • Any percussion dullness?

  • Any cyanosis?

  • Any diminished breath sounds?

  • Any URI symptoms?

  • Any edema?

  • Any lymphadenopathy?

 

Labs:​​ 

  • CBC with​​ white blood cell count

  • Lactic acid

  • Arterial blood gas (ABG)

  • Blood cultures

  • Sputum cultures

  • Respiratory virus panel

 

Diagnostic Tests:

  • Chest x-ray

 

Assessment

 

Discussion

 

This is an 84 y/o M with symptoms concerning for PNA​​ such as fever,​​ fatigue,​​ tachypnea, cough with sputum,​​ shortness of breath,​​ and hypoxemia. ​​ Patient comes from home with no recent hospital stay, making this a suspected CAP. ​​ Additional testing is pending to rule out other diagnoses and confirm PNA. ​​ Waiting on results of ABG to grade​​ severity of​​ hypoxemia but may be​​ moderate considering​​ spO2​​ of 89%​​ (Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017).

 

Differential Diagnoses:

  • Community acquired​​ pneumonia

  • Bronchitis

  • Acute COPD exacerbation

  • Upper respiratory infection

  • Heart failure

  • Allergic rhinitis

  • Pulmonary embolism

  • Plural effusion

  • Tuberculosis

  • Influenza

 

(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017).

 

Problem List and Management Plan

  • Acute hypoxemia​​ with suspected CAP

    • Admit to inpatient​​ floor

    • Titrate supplemental O2 to maintain O2​​ saturation​​ > 92%

    • Aggressive pulmonary hygiene including frequent incentive spirometry use.

    • STAT ABGs

    • STAT CXR

    • STAT blood cultures

    • Start empiric antibiotic coverage​​ for suspected CAP: ​​​​ Ampicillin-sulbactam 1.5mg Q6 IV, Azithromycin 500mg IV daily. ​​ Will observe for improvement over the course of 48​​ hours​​ and if no improvement consider changing antibiotics and adding vancomycin for Methicillin-resistant Staphylococcus aureus (MRSA) coverage

    • Start Guaifenesin 1200mg PO Q6

  • HTN, controlled.

    • Continue metoprolol 25mg PO BID

    • Continue ASA 81mg PO daily

  • Seasonal allergies

    • Continue Claritin PRN (clarify dosage)

  • FEN: ​​ Bedside swallow evaluation to rule out aspiration. ​​ If pass: ​​ start regular diet, saline lock IV. ​​ If fail: ​​ make NPO, call provider for IVF orders.

  • DVT prophylaxis:  SCDs

  • Follow up plan: ​​ Will be followed daily by​​ the​​ hospitalist​​ service.

 

(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017).

 

Patient Education:

 Inform patient on need for admission based on hypoxemia and need to treat suspected CAP.

Case Analysis

The​​ patient presented with symptoms of a cough with yellow sputum, shortness of breath, hypoxemia, low grade temperature, mild tachypnea,​​ borderline tachycardia,​​ and fatigue. ​​ Per​​ Bartlett (2018), these symptoms are suggestive of pneumonia, and considering that the patient lives at home, this would be considered a community acquired pneumonia (CAP). ​​ Bartlett also states that additional typical findings of a CAP include pleuritic chest pain, as well as nausea, vomiting, diarrhea, chills, and rigors, so these items would be inquired about in the history of present illness, review of systems, and physical examination. ​​ I would also inquire if the patient were around any sick individuals or has had any issues swallowing (aspiration) that may point towards an etiology​​ (Bartlett, 2018). ​​​​ 

 Upon examination of the chest x-ray​​ (CXR)​​ results of patients with a CAP,​​ Bartlett (2018)​​ states that infiltrates are​​ a​​ typical​​ finding. ​​ Additionally, Bartlett states that​​ consolidation​​ in the lobes​​ is another​​ frequent finding​​ of CAP, and that there may or may not be cavitation present. ​​​​ Bartlett also states that the radiograph should be a minimum of two views, and that a CXR is typically sufficient in diagnosing pneumonia without the need for a computed tomography (CT) scan, although such a test can clarify an ambiguous CXR image​​ (Bartlett, 2018). ​​​​ According to​​ Papadakis and McPhwee (2018), a pulmonary opacity is required to create a diagnosis of CAP on a CXR.

 Upon examination of the patient’s AGBs, I would expect to find respiratory alkalosis. ​​ Theodore (2017) states that the most common cause of respiratory alkalosis is hyperventilation. ​​ Given that the​​ patient is slightly tachypneic and​​ likely compensating for being​​ hypoxemic, he could be​​ lowering his carbon dioxide level​​ through overexcretion in the alveoli of the lungs​​ (Theodore, 2017). ​​ As to whether or not his gases are compensated is unknown, but if it were​​ compensated then he would have an elevated bicarbonate level​​ (Theodore, 2017). ​​​​ The​​ patient’s partial pressure of oxygen (paO2)​​ level is likely low given the spO2 of 89% on room air, and according to the oxyhemoglobin dissociation curve, it is​​ possible​​ that he is​​ moderately​​ hypoxemic with a paO2 of under 60​​ (Papadakis & McPhwee, 2018; Theodore, 2017; UpToDate, 2018).

 Per​​ Yealy and Fine (2017), there is a tool called the​​ community acquired pneumonia​​ severity index​​ (PSI)​​ which can assist providers in determining whether or not to admit patients for a CAP. ​​ The index places patients in classes with class I being associated with the lowest mortality, and class V being associated with the highest mortality. ​​ The creators of the tool state that patients in classes I-III may be treated outpatient, but that IV and V should be admitted for treatment, particularly in cases of hypoxemia. ​​ Per the​​ PSI​​ calculator provided by​​ UpToDate (n.d.), the patient in this case study is deemed a class IV with a score of 94 and should therefore be admitted to the hospital. ​​​​ This score was due to the patient’s advanced age and hypoxemia.

 The patient is without medication allergies and considering his hypoxemia he is at an increased mortality risk according to the previously mentioned PSI calculator. ​​​​ Per​​ Bartlett (2018), the presence of colored sputum is more often associated with bacterial pneumonia versus viral. ​​ Therefore, his treatment should include empiric antibiotic coverage. ​​ According to​​ File (2018), the patient is without risk factors for pseudomonas or antibiotic resistance due to no stated recent antibiotic use, recent hospitalizations, or high risk living situations. ​​ For this​​ type of patient, File recommends a combination treatment with a beta-lactam and a macrolide such as ampicillin-sulbactam and azithromycin​​ (File, 2018).

 

References

Bartlett, J. G. (2018). Diagnostic approach to community-acquired pneumonia in adults.​​ UpToDate. Retrieved from https://www-uptodate-com.proxy.library.maryville.edu/contents/diagnostic-approach-to-community-acquired-pneumonia-in-adults

File, T. M. (2018). Treatment of community-acquired pneumonia in adults who require hospitalization. Retrieved September 1, 2018, from https://www-uptodate-com.proxy.library.maryville.edu/contents/treatment-of-community-acquired-pneumonia-in-adults-who-require-hospitalization?search=cap&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2

Papadakis, M. A., & McPhwee, S. J. (Eds.). (2018).​​ Current medical diagnosis & treatment 2018​​ (57th ed.). United States: McGraw-Hill.

Theodore, A. C. (2017). Arterial blood gases.​​ UpToDate. Retrieved from https://www-uptodate-com.proxy.library.maryville.edu/contents/arterial-blood-gases

UpToDate. (2018). Hemoglobin oxygen dissociation curve. Retrieved September 5, 2018, from https://www-uptodate-com.proxy.library.maryville.edu/contents/image?topicKey=HEME%2F7072&view=machineLearning&search=hemoglobin%20dissociation%20curve&sectionRank=1&imageKey=HEME%2F81216&rank=1~150&source=machineLearning&sp=0

UpToDate. (n.d.). Calculator: Community-acquired pneumonia severity index (PSI) for adults. Retrieved September 1, 2018, from https://www-uptodate-com.proxy.library.maryville.edu/contents/calculator-community-acquired-pneumonia-severity-index-psi-for-adults?source=see_link

Yealy, D. M., & Fine, M. J. (2017). Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care - UpToDate. Retrieved September 1, 2018, from https://www-uptodate-com.proxy.library.maryville.edu/contents/community-acquired-pneumonia-in-adults-assessing-severity-and-determining-the-appropriate-site-of-care?topicRef=7027&source=see_link#H1148992221

 

 

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