NRNP 6540 Week 5 Case Assignment

Case Title: A 67-year-old With Tachycardia and Coughing
Ms. Jones is a 67-year-old female who is brought to your office today by her daughter
Susan. Ms. Jones lives with her daughter and is able to perform all activities of daily
living (ADLs) independently. Her daughter reports that her mother’s heart rate has been
quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a
30-pack per year history of smoking cigarettes but quit smoking 3 years ago. Other
known history includes chronic obstructive pulmonary disease (COPD), hypertension,
vitamin D deficiency, and hyperlipidemia. She also reports some complaints of
intermittent pain/cramping in her bilateral lower extremities when walking, and has to
stop walking at times for the pain to subside. She also reports some pain to the left side
of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-
tinged sputum. She states she has COPD and has been using her albuterol inhaler
more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies
any worsening shortness of breath. She admits that she has some weakness and
fatigue but is still able to carry out her daily routine.
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component Value CBC Component Value
Glucose, Serum 86 mg/dL White blood cell count 5.0 x 10E3/uL
BUN 17 mg/dL RBC 4.71 x10E6/uL
Creatinine, Serum 0.63 mg/dL Hemoglobin 10.9 g/dL
EGFR 120 mL/min Hematocrit 36.4%
Sodium, Serum 141 mmol/L Mean Corpuscular Volume 79 fL
Potassium, Serum 4.0 mmol/L Mean Corpus HgB 28.9 pg
Chloride, Serum 100 mmol/L Mean Corpus HgB Conc 32.5 g/dL
Carbon Dioxide 26 mmol/L RBC Distribution Width 12.3%
Calcium 8.7 mg/dL Platelet Count 178 x 10E3/uL
Protein, Total, Serum 6.0 g/dL
Albumin 4.8 g/dL
Globulin 2.4 g/dL
Bilirubin 1.0 mg/dL
AST 17 IU/L
ALT 15 IU/L
Allergies: Penicillin
Current Medications:
ï‚· Atorvastatin 40mg p.o. daily NRNP 6540 Week 5 Case Assignment

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ï‚· Multivitamin 1 tablet daily
ï‚· Losartan 50mg p.o. daily
ï‚· ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
ï‚· Caltrate 600mg+ D3 1 tablet daily

Diagnosis: Pneumonia
Directions: Answer the following 10 questions directly on this template.

Question 1: What findings would you expect to be reported or seen on her chest X-ray results, given the diagnosis of pneumonia?

Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?

Question 3:
ï‚· 3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?

ï‚· 3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.

Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?

Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?

Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning.
a. DVT (Deep Vein Thrombosis)
b. Intermittent Claudication
c. Cellulitis
d. Electrolyte Imbalance

Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?

Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.

Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?

Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.

Case Study: PNA

Question 1: What findings would you expect to be reported or seen on her chest X-ray results, given the diagnosis of pneumonia?

Focal or diffuse opacities signal pneumonia in patients with a fever, chills, or cough (Amanullah, 2023). Chest X-rays of patients with pneumonia commonly reveal regions of consolidation or infiltrates characterized by opaqueness that masks the lung tissue in a white or gray shadowy area. The appearance varies depending on the specific type of pneumonia (bacterial versus viral) and the precise site of infection within the pulmonary system. Air bronchograms, the silhouette sign, parapneumonic effusions, and pneumonia-related sequelae such as lung abscesses and atelectasis are further signs of pneumonia (Amanullah, 2023).

Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia). What’s the difference/criteria? NRNP 6540 Week 5 Case Assignment

Based on the absence of any documented hospitalization or healthcare interventions in the patient’s medical history, it is probable that Ms. Jones has been diagnosed with community-acquired pneumonia (CAP). Infection of the pulmonary parenchyma acquired from exposure in the community (Sayiner & Duru Çetinkaya, 2023). The origin of CAP is external to the confines of the hospital environment. On the other hand, hospital-acquired pneumonia (HAP) is developed during hospitalization, usually occurring 48 hours or later following admission.

Question 3:
3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?

The CURB-65 score is frequently utilized to assess the gravity of pneumonia and offer guidance on treatment choices. The CRB-65 tool is suggested as the most useful tool in a primary care context by the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) (Freij et al., 2020). It assesses several indicators, including Confusion, Urea >7mmol/L, Respiratory rate ≥30/min, Blood pressure (systolic <90mmHg or diastolic ≤60mmHg), and age ≥65 years.

3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.

Confusion: Not mentioned in the case.

Urea: BUN is 17mg/dL (within normal limits).

Respiratory rate: 22/min.

Blood pressure: 126/78.

Age: 67 years.

Based on the obtained score of 1 point (attributed to her age being older than 65), it can be inferred that she is experiencing mild pneumonia, indicating that outpatient treatment would likely suffice.

Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be based on her diagnosis, case scenario, and evidence-based guidelines?

            Inflammation of the intra-alveolar space that affects the lower lobe of the lungs is known as lower lobe pneumonia. Given her advanced age, pre-existing COPD condition, and the clinical symptoms indicative of community-acquired pneumonia, an effective therapeutic approach would involve administering a combination therapy consisting of a macrolide class antibiotic such as azithromycin along with a beta-lactam antibiotic like amoxicillin or cefpodoxime (Regunath & Oba, 2022). However, it is crucial to consider her documented penicillin allergy when choosing the appropriate antibiotic regimen.

Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?

Spirometry is required to provide an authoritative diagnosis of COPD, with a postbronchodilator FEV1/FVC ratio of 0.70 demonstrating ongoing airflow limitation (Laisure et al., 2021). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations divide patients into four categories based on their level of airflow limitation: GOLD 1 (mild), GOLD 2 (moderate), GOLD 3 (severe), or GOLD 4 (extremely severe) (Agustí et al., 2023).

Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best for a potential diagnosis? Explain your reasoning.
a. DVT (Deep Vein Thrombosis)
b. Intermittent Claudication
c. Cellulitis
d. Electrolyte Imbalance

1. Intermittent Claudication. The symptoms reported are typical of intermittent claudication, a leg pain caused by a lack of blood flow, frequently caused by peripheral artery disease. Intermittent claudication (IC) is a type of skeletal muscle discomfort that develops in the lower extremities during activity (Patel & Surowiec, 2023). When there is insufficient oxygen delivery to meet the metabolic needs of the skeletal muscles, IC develops. It usually occurs during walking and is eased by rest.

Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to evaluate this further?

An ankle-brachial index (ABI) would be a suitable first test. If the ABI indicates peripheral artery disease, further imaging may be performed, such as a Doppler ultrasonography of the leg arteries. An ABI is a ratio of ankle blood pressure to arm blood pressure. An ABI of 0.9-1.3 is typical (Patel & Surowiec, 2023). Claudication is prevalent in people with ABIs ranging from 0.4 to 0.9. An ABI between 0.4 and 1.3 indicates more severe peripheral artery disease, and an ABI greater than 1.3 indicates non-compressible calcified arteries. NRNP 6540 Week 5 Case Assignment

Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.

Acute exacerbation of COPD

Congestive heart failure

Pulmonary embolism

Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?

Ms. Jones should be informed about several key aspects of her health condition:

• Understanding the significance of adhering to prescribed medication regimens.
• Identifying indications implying deterioration in pneumonia or COPD and knowing when to seek medical assistance (Rothberg, 2022).
• Implementing good respiratory hygiene practices, including using a spacer with her inhaler, avoiding irritants, and engaging in deep breathing exercises (Rothberg, 2022).
• Acknowledging the importance of vaccinations for pneumonia and influenza prevention (Rothberg, 2022).
• Making lifestyle adjustments that effectively manage leg pain, such as participating in supervised exercise therapy programs.
• Jones should also schedule a follow-up appointment within a 5-7-day timeframe so that healthcare providers can monitor treatment progress; however, earlier assessment may be warranted if symptoms worsen.

Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.

            Yes, amoxicillin/clavulanate (Augmentin) in combination with a macrolide such as azithromycin could be possible for Ms. Jones’ treatment. This combination is effective against most CAP pathogens (Ayoade, 2023). However, given Ms. Jones’ penicillin allergy, amoxicillin/clavulanate should be used cautiously. The nature and severity of her allergy would determine whether she could take this drug safely. If her penicillin response was severe, a different antibiotic might be preferable.

References

Agustí, A., Celli, B. R., Criner, G. J., Halpin, D., Anzueto, A., Barnes, P., Bourbeau, J., Han, M. K., Martinez, F. J., Montes de Oca, M., Mortimer, K., Papi, A., Pavord, I., Roche, N., Salvi, S., Sin, D. D., Singh, D., Stockley, R., López Varela, M. V., … Vogelmeier, C. F. (2023). Global initiative for chronic obstructive lung disease 2023 report: GOLD executive summary. The European Respiratory Journal: Official Journal of the European Society for Clinical Respiratory Physiology, 61(4), 2300239. https://doi.org/10.1183/13993003.00239-2023

Amanullah, S. (2023, June 13). Typical bacterial pneumonia imaging. Medscape.com. https://emedicine.medscape.com/article/360090-overview

Ayoade, F. O. (2023, April 4). Community-acquired pneumonia empiric therapy. Medscape.com. https://emedicine.medscape.com/article/2011819-overview

Freij, M., Dullabh, P., Donaldson, K., Islam, S., Shiffman, R., & Kashyap, N. (2020). Clinical Decision Support for Community-Acquired Pneumonia. Clinical Decision Support for Community-Acquired Pneumonia.

Laisure, M., Covill, N., & Ostroff, M. L. (2021, July 21). Summarizing the 2021 updated GOLD guidelines for COPD. Uspharmacist.com. https://www.uspharmacist.com/article/summarizing-the-2021-updated-gold-guidelines-for-copd

Patel, S. K., & Surowiec, S. M. (2023). Intermittent Claudication. StatPearls Publishing.

Regunath, H., & Oba, Y. (2022). Community-acquired pneumonia. StatPearls Publishing.

Rothberg, M. B. (2022). Community-acquired pneumonia. Annals of Internal Medicine, 175(4), ITC49–ITC64. https://doi.org/10.7326/aitc202204190

Sayiner, A., & Duru Çetinkaya, P. (2023). Community-acquired pneumonia. In Airway diseases (pp. 1–23). Springer International Publishing. NRNP 6540 Week 5 Case Assignment