Alterations In Pulmonary Function Assignment

PATIENT CASE BACTERIAL PNEUMONIA

Chief Complaints

Provided by patient’s home caregiver: “Mrs. I. is confused and very sick. She was up most of last night coughing.”

HPI

Mrs. B.I. is an 84-year-old white female, who is widowed and a retired bank manager. She owns her own home and has a 45-year-old female caregiver who lives in the home. Currently Mrs. I. uses a walker and takes daily strolls to the park with her caregiver. She is able to perform most activities of daily living; however, the caregiver prepares all meals. The patient presents to the clinic accompanied by her caregiver, who reports that Mrs. I. has a one-week history of upper respiratory symptoms and a two-day history of increasing weakness and malaise. Approximately three days ago, the patient developed a cough that has gradually become worse and she now has difficulty catching her breath. The caregiver also reports that the patient was confused last night and nearly fell while going to the bathroom. The patient has been coughing up a significant amount of phlegm that is thick and green in color. She has no fever. The caregiver has become concerned by the patient’s reduction in daily activities and an inability to get rid of her “cold.” Patient Case Question 1. Based on the patient’s history of illness, is this type of infection considered community-acquired or nosocomial? Alterations In Pulmonary Function. Alterations In Pulmonary Function Assignment

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PMH

Tobacco dependence × 64 years Chronic bronchitis for approximately 13 years Urinary overflow incontinence × 10 years HTN × 6 years, BP has been averaging 140/80 mm Hg with medication Mild left hemiparesis caused by CVA 4 years ago Depression × 2 years Constipation × 6 months Influenza shot 3 months ago FH (+) for HTN and cancer (−) for CAD, asthma, DM

SH

Patient lives with caregiver in patient’s home Smokes 1/2 ppd Some friends recently ill with “colds” Occasional alcohol use, none recently

ROS

Difficult to conduct due to patient’s mental state (lethargy present) Caregiver states that patient has had difficulty sleeping due to persistent cough Caregiver has not observed any episodes of emesis but reports a decrease in appetite Caregiver denies dysphagia, rashes, and hemoptysis

Patient Case Question 2. Provide a clinical definition for lethargy

Meds

Atenolol 100 mg po QD HCTZ 25 mg po QD

Aspirin 325 mg po QD Nortriptyline 75 mg po QD

Combivent MDI 2 puffs QID (caregiver reports reports patient rarely uses)

Albuterol MDI 2 puffs QID PRN Docusate calcium 100 mg po HS

All PCN (rash) 

PE and Lab Tests

Gen

The patient’s age appears to be consistent with that reported by the caregiver. She is well groomed and neat, uses a walker for ambulation, and walks with a noticeable limp. She is a lethargic, frail, thin woman who is oriented to self only. The patient is also coughing and using accessory muscles to breathe. She is tachypneic and appears to be uncomfortable and in moderate respiratory distress. Alterations In Pulmonary Function

Vital Signs See Patient Case Table 13.1

Skin

Warm and clammy (−) for rashes HEENT NC/AT EOMI PERRLA Fundi without lesions Eyes are watery Nares slightly flared; purulent discharge visible Ears with slight serous fluid behind TMs Pharynx erythematous with purulent post-nasal drainage Mucous membranes are inflamed and moist

Neck

Supple Mild bilateral cervical adenopathy (−) for thyromegaly, JVD, and carotid bruits

Lungs/Thorax

Breathing labored with tachypnea RUL and LUL reveal regions of crackles and diminished breath sounds RLL and LLL reveal absence of breath sounds and dullness to percussion (−) egophony

Cardiac

Regular rate and rhythm Normal S1 and S2 (−) for S3 and S4

Abd

Soft and NT Normoactive BS (−) organomegaly, masses, and bruits

Genit/Rect Examination deferred

MS/Ext (−) CCE Extremities warm Strength 4/5 right side, 1/5 left side Pulses are 1 + bilaterally

Neuro Oriented to self only CNs II–XII intact DTRs 2 + Babinski normal

Laboratory Blood Test Results See Patient Case Table 13.2

Patient Case Question 5. Should this patient be admitted to the hospital for treatment? Patient Case Question 6. What is this patient’s 30-day mortality probability?

Patient Case Question 7. Identify two clinical signs that support a diagnosis of “double pneumonia.”

Patient Case Question 8. Identify five risk factors that have predisposed this patient to bacterial pneumonia.

Patient Case Question 9. Identify a minimum of twenty clinical manifestations that are consistent with a diagnosis of bacterial pneumonia.

Patient Case Question 10. Propose a likely microbe that is causing bacterial pneumonia in this patient and provide a strong rationale for your answer.

Patient Case Question 11. Identify two antimicrobial agents that might be helpful in treating this patient.

Patient Case Question 12. The patient has no medical history of diabetes mellitus, yet her fasting serum glucose concentration is elevated. Propose a reasonable explanation.

Patient Case Question 13. Why is this patient afebrile? Alterations In Pulmonary Function Assignment

Patient Case Question 14. Is there a significant probability that bacterial pneumonia may have developed from a urinary tract infection in this patient?

Patient Case Question 15. Explain the pathophysiologic basis that underlies the patient’s high blood pH. Patient Case Question 16. The chest x-ray shown in Patient Case Figure 13.1 reveals pneumonia secondary to infection with Mucor species in a patient with poorly controlled diabetes mellitus. Where is pneumonia most prominent: right upper lobe, right lower lobe, left upper lobe, or left lower lobe?

 

PATIENT CASE FIGURE 13.1

Chest x-ray from a patient with pneumonia due to infection with Mucor. See Patient Case Question 16. (Reprinted with permission from Crapo JD, Glassroth J, Karlinsky JB, King TE Jr. Baum’s Textbook of Pulmonary Diseases, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2004.)

 

Bruyere, Harold J.. 100 Case Studies in Pathophysiology (Kindle Locations 1434-1453). Wolters Kluwer Health. Kindle Edition. Alterations In Pulmonary Function Assignment