NURS 682 CAP Case Study 11
NURS 682 CAP Case Study 11
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LIENHARD SCHOOL OF NURSING
DEPARTMENT OF GRADUATE STUDIES
Case Study: Community Acquired Pneumonia
Chief Complaint
“I have been short of breath and have been coughing up rust-colored phlegm for the past 3 days.”
HPI
James Thompson is a 55-year-old African American man with a 3-day history of worsening shortness of breath, subjective fevers, chills, right sided chest pain, and a productive cough. The patient states that his initial symptom of shortness of breath began approximately 1 week ago after delivering mail on an extremely cold winter day. He has been taking ibuprofen and an over-the-counter cough and cold preparation but feels that his symptoms are getting “much worse.” The patient began experiencing right sided pleuritic chest pain and a productive cough with rust colored sputum over the past 3 days and feels that he has been feverish with chills, although he did not take his temperature. On presentation to the ED, he is febrile and visibly short of breath.
PMH
Hypertension × 15 years
Dyslipidemia × 15 years
Type 2 diabetes mellitus × 10 years
FH
Adopted; unknown birth parents
SH
Lives with wife and four children. Employed as a mail carrier for the US Postal Service. Denies alcohol, tobacco, or intravenous drug use.
Medications
Lisinopril 10 mg orally once daily
Hydrochlorothiazide 25 mg orally once daily
Atorvastatin 20 mg orally once daily
Metformin 1000 mg orally twice daily
Ibuprofen 200 mg PO Q 6 H as needed for pain and fever
Guaifenesin/dextromethorphan (100 mg/10 mg/5 mL) two teaspoonfuls every 4 hours as needed for cough
All
NKDA
ROS
Patient is a good historian. He has been experiencing shortness of breath, a productive cough with rust colored sputum, subjective fevers, chills, and pleuritic chest pain that is “on the right side of my chest.” He denies any nausea, vomiting, constipation, or problems urinating.
Physical Examination
Gen
Patient is a well-developed, well-nourished, African American man in moderate respiratory distress appearing somewhat anxious and uncomfortable.
VS
BP 155/85, P 127, RR 30, T 39.5°C; Wt 110 kg, Ht 5′11″
Skin
Warm to the touch; poor skin turgor
HEENT
PERRLA; EOMI; dry mucous membranes
Neck/Lymph Nodes
No JVD; full range of motion; no neck stiffness; no masses or thyromegaly; no cervical lymphadenopathy
Lungs/Thorax
Tachypneic, labored breathing; coarse rhonchi throughout right lung fields; decreased breath sounds in right middle and right lower lung fields
CV
Audible S1 and S2; tachycardic with regular rate and rhythm; no MRG
Abd
NTND; (+) bowel sounds
Genit/Rect
Deferred
Extremities
No CCE; 5/5 grip strength; 2+ pulses bilaterally
Neuro
A&O × 3; CN II–XII intact
Labs on Admission
ABG
pH 7.38; PaCO2 29; PaO2 70 with 87% O2 saturation on room air
Chest XRay
Right middle and right lower lobe consolidative airspace disease, likely pneumonia. Left lung is clear. Heart size is normal.
Chest CT Scan Without Contrast
No axillary, mediastinal, or hilar lymphadenopathy. The heart size is normal. There is consolidation of the right lower lobe and lateral segment of the middle lobe, with air bronchograms. No significant pleural effusions. The left lung is clear.
Sputum Gram Stain
>25 WBCs/hpf, <10 epithelial cells/hpf, many gram (+) cocci in pairs
Sputum Culture
Pending
Blood Cultures × Two Sets
Pending
Other Lab Tests
Streptococcus pneumoniae urine antigen—Pending
Legionella pneumophila urine antigen—Pending
Assessment
Probable multi-lobar CAP involving the RML and RLL
Clinical Course
While in the ED, the patient was placed on 4 L NC of O2, and his oxygen saturation improved to 98%. The patient was initiated on ceftriaxone 1 g IV daily and azithromycin 500 mg IV daily and admitted to the hospital. Over the next 48 hours, the patient’s clinical status improved with decreasing fever, tachypnea, tachycardia, and shortness of breath. On hospital day 2, the S. pneumoniae urine antigen was positive, and the sputum culture demonstrated the growth of S. pneumoniae, resistant to erythromycin (MIC ≥1 mcg/mL), but susceptible to penicillin (MIC ≤2 mcg/mL), ceftriaxone
(MIC ≤1 mcg/mL), levofloxacin (MIC ≤0.5 mcg/mL), and vancomycin (MIC ≤1 mcg/mL).
NURS 682 Advanced Pathophysiology for Advanced Practice Nursing
Case Study Assignment
- WHAT ARE THE GOALS OF TREATMENT?
- WHAT IS THE RATIONALE FOR CHOOSING THE PHARMACO THERAPEUTIC PLAN?
- DISCUSS THE APPROPRIATENESS OF DRUG THERAPY AND DURATION OF TREATMENT.
- WHAT ARE MONITORING PARAMETERS? (Assess for clinical efficacy and adverse effects)
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