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Running Head: Comprehensive Case Study

Comprehensive Case Study

Lauren Makosky

Walsh University

NURS 640: Clinical Assessment and Management

April 26, 2021

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Comprehensive Case Study
Subjective Assessment
Patient presents to the office today with complaints of a cough and cold symptoms for

one week. Beginning two days ago the patient noticed blood in his sputum. This morning He

noticed some chest pain when he exerted himself that lasted for approximately 30 seconds. The

patient states that he has had similar pain in the past. The patient has attempted to take an over-

the-counter cough medicine with little relief. The patient admits to visiting his wife regularly in

the nursing home two to three times a week. He has a history of COPD that he treats with a

Spiriva inhaler daily and an Albuterol inhaler as needed, hypertension in which he treats with

Lisinopril and Metoprolol daily, Hyperlipidemia that he treats with simvastatin daily. The patient

also has a history of coronary artery disease in which he had to undergo two coronary artery

bypass grafts five years ago and now controls this with a daily aspirin. The patient has a surgical

history of an appendectomy in 1980. The patient denies any nausea or vomiting, dizziness, or

headaches. The patient also denies any recent travel. The patient denies alcohol and illicit drug

use. The patient admits to being a previous smoker, but he quit five years ago, he previously

smoked one pack per day for 50 years.

Additional subjective information that is important to collect is if the problem has been

experienced in the past. Another good question is if the complaint has worsened over time or if it

is beginning to get better. I would also like to know where the patient lives, if he works and if he

was exposed to any sick individuals. This information is significant because if the patient was

exposed, we could narrow down the diagnosis by what he encountered. I also would like to know

the severity and exact locations of his problems and have him describe the characteristics he is

feeling. I also would like to know what over the counter medication the patient tried that

provided him with some relief and for how long the relief was provided.
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Objective Assessment

Patient presents to the office with the following vital signs, blood pressure 90/54, pulse

130 beats per minute irregular, temperature 101.2 Degrees Fahrenheit, respiratory rate 32 breaths

per minute. Upon exam, the patient has mildly elevated jugular vein distention, expiratory

wheezing bilaterally, irregular heart rate with a III/VI systolic ejection murmur, active bowel

sounds in all four quadrants with a non-distended, soft, nontender abdomen, trace pedal edema,

lower extremity pulses are palpable bilaterally and are 2+, and the patient skin is pale, cool and

clammy. There is no lab work or radiology imaging provided.

Additional objective data that would be helpful in diagnosing this patient would be to

know whether the patient is able to provide a history without respiratory discomfort. Assessing

the patients breathing pattern and general coloring as he talks would also be helpful. Inspecting

the patient’s chest movements is important to see if they are using accessory muscles to breathe

and weather the chest wall is symmetrical (Goolsby & Grubbs, 2019). Other objective

information that would be helpful to collect from this patient is pulse oximetry, radiology

imaging and blood work.

Pathophysiology of Diagnosis

Based on subjective and objective information provided, I believe that the patient is

presenting today with community-acquired pneumonia, which occurs outside of the hospital.

Pneumonia involves inflammation and consolidation of lung tissue, the cause is most often

Streptococcus pneumoniae, Haemophilus influenzae, or Staphylococcus aureus (Goolsby &

Grubbs, 2019). Using the community-acquired pneumonia decision rule can help diagnose this

disease. This decision rule provides framework for determining whether the patient diagnosed

with community-acquired pneumonia can be safely monitored and treated at home, one point is
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awarded for each of the following factors present, confusion of new onset, BUN >20 mg/dL,

respiratory rate of greater than 30 breaths per minute, blood pressure less than 90 mmHg systolic

or diastolic less than 60 mmHg, Age 65 or older (Goolsby & Grubbs, 2019). The patient

Presented to the office with a respiratory rate of 32 breaths per minute, a blood pressure of 90/54

and is 78 years old. This decision rule also states if the blood urea nitrogen is unavailable, may

omit and then adjust the scoring system. Patients that score a three to five typically require

hospitalization for observation therapy, and this patient scored a four out of five (Goolsby &

Grubbs, 2019).

Another reason I believe that the patient has community-acquired pneumonia is based on

presenting signs and symptoms. The patient is presenting with a cough for one-week, bloody

sputum, chest pain on exertion, low blood pressure, tachycardia, fever, tachypnea, wheezing and

admitting to visiting his wife in a nursing home two to three times a week. Signs and symptoms

of pneumonia can vary but commonly the patient complains of cough associated with fever,

malaise, shaking, chills, rigors, and/or chest discomfort, abnormal vital sings include

tachycardia, tachypnea and fever (Goolsby & Grubbs, 2019). Pneumonia can also produce low or

high pitched, inspiratory or expiratory Ronchi or wheezes (Goolsby & Grubbs, 2019).

Differential Diagnoses

Other diagnoses I am considering for this patient are acute bronchitis, congestive heart

failure, and bronchiectasis. Acute bronchitis is commonly encountered in ambulatory care and

effects people of all ages, it involves inflammatory processes of the bronchial smooth muscles

and is associated with a wide range of microorganisms that are usually viral (Goolsby & Grubbs,

2019). Cough is the most common symptom of bronchitis and may continue for several weeks

after the initial infection resolves, the cough may be productive. Associated symptoms include
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Comprehensive Case Study
fever, malaise, chest discomfort, chills, headache, and there may be wheezes on auscultation

(Goolsby & Grubbs, 2019). This diagnosis is supported by the patient’s fever, cough, bloody

sputum, wheezes and history of smoking. However, the chills and chest discomfort are mild

compared to the symptoms of pneumonia, which supports my first choice of pneumonia

(Goolsby & Grubbs, 2019). The patient is also not exhibiting symptoms of malaise or headache.

Another way to confirm that the patient does not have acute bronchitis is to order a chest Xray to

rule out pneumonia.

According to The American Journal of Cardiology, In the usual form of heart failure, the

heart muscle has reduced contractility which produces a reduction in cardiac output, and then

becomes inadequate to meet the peripheral demands of the body (Parmley, 1985). Class II heart

failure patients have a slight limitation of physical activity, they are comfortable at rest, but

ordinary physical activity results in symptoms of fatigue, dyspnea, palpitation, or anginal

discomfort (Goolsby & Grubbs, 2019). Common symptoms of heart failure are dyspnea with

exertion or rest, orthopnea, edema, tachycardia and cough (Goolsby & Grubbs, 2019). This

diagnosis is supported by trace pedal edema, tachycardia, cough and mild jugular vein distention.

Although, the fever supports an infectious process.

Bronchiectasis involves dilation of one or more bronchi (Goolsby & Grubbs, 2019).

usually with this diagnosis, there is a history of chronic, productive cough and sputum is

typically mucopurulent and is produced in increased amounts. If the patient has advanced

bronchiectasis, clubbing and cyanosis may be present. This diagnosis is supported by shortness

of breath, wheezing and bloody sputum. However, the patient presented to the office with a new

onset cough lasting one week, so this does not support bronchiectasis because patients with this

diagnosis typically have a chronic cough.

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Plan

Based on the recommendations from the community acquired pneumonia decision rule I

would like to admit the patient to the hospital for monitoring. To confirm the diagnosis of

community acquired pneumonia, according to the U.S. National Library of Medicine, I would

like to order a chest X Ray to check any areas of infiltrates, check pulse oximetry which will

provide a simple way to look at the patient’s blood oxygen levels to see if the patient requires

oxygen therapy, order a complete blood count daily and blood cultures to look at the patient's

white blood cell count and to see if the infection has spread to the bloodstream (US National

Library of Medicine, 2021). I would also order a sputum culture to see what bacteria the patient

has; this will determine antibiotic treatment.

The American Thoracic Society and Infectious Diseases Society of America recommends

adults with comorbidities to receive combination antibiotic therapy like amoxicillin/clavulanate

500 mg/125 mg three times daily, or amoxicillin/ clavulanate 875 mg/125 mg twice daily, or

2,000 mg/125 mg twice daily, or a cephalosporin (cefpodoxime 200 mg twice daily or

cefuroxime 500 mg twice daily) (Metlay et al., 2019). I would also prescribe as needed albuterol

treatments for wheezing, and Tylenol as needed to control fevers. The patient has a history of

coronary artery disease and had coronary artery bypass graft so while in the hospital I would

order lovenox 40mg subcutaneous injection twice daily to help prevent blood clots because the

patient will not be moving as much as he normally would be at home. I would order continuous

normal saline drip at 75mL per hour for hydration. I would only have it run at 75mL per hour

because the patient already has mild jugular vein distention and trace pedal edema.

Follow-Up Recommendations
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According to the Cleveland Clinic, receiving all recommended vaccinations is one of the

best ways to prevent pneumonia (Cleveland Clinic, 2021). Other ways to help prevent

pneumonia include, washing your hands before eating, before handling food, after using the

restroom, and after being outside, it is okay to use an alcohol-based hand sanitizer; Avoid being

around people who are sick, what's up everybody do not touch or share objects that are shared

with other people, eating a healthy diet, exercise, and getting enough rest keeps the immune

system strong (Cleveland Clinic, 2021). Also providing education on how pneumonia is spread

from person to person, this is done when droplets of fluid containing the pneumonia bacteria or

virus are launched in the air when someone coughs or sneezes and then inhaled by other people,

one can also get pneumonia from touching an object previously touched by someone else with

pneumonia then touching your nose or mouth without washing your hands (Cleveland Clinic,

2021). If a patient has bacterial pneumonia, they are considered contagious until the second day

after antibiotics and when one no longer has a fever.

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References:

Goolsby, M. J., & Grubbs, L. (2019). Advanced assessment: interpreting findings and

formulating differential diagnoses. F.A. Davis Company.

Metlay, J. P., Watere, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … Flanders, S.

A. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An

Official Clinical Practice Guideline of the American Thoracic Society and Infectious

Diseases Society of America. American Thoracic Society Documents, 200(7).

https://doi.org/https://doi.org/10.1164/rccm.201908-1581ST

Parmley, W. W. (1985). Pathophysiology of congestive heart failure. The American Journal of

Cardiology, 56(2). https://doi.org/https://doi.org/10.1016/0002-9149(85)91199-3

Pneumonia: Symptoms, Treatment, Causes & Prevention. Cleveland Clinic. (2021).

https://my.clevelandclinic.org/health/diseases/4471-pneumonia.

U.S. National Library of Medicine. (2021, January 4). Pneumonia | Pneumonia Symptoms |

Signs of Pneumonia. MedlinePlus. https://medlineplus.gov/pneumonia.html.