Running Head: Case Study

Case Study

Daziana Velasquez

Walsh University

NURS 640- Clinical Assessment and Management

Angie Gager, MSN, FNP-BC

April 26, 2021

2
CASE STUDY

A 78 year old male presents to the office with a complaint of cold symptoms with a

cough that has been present for one week. In addition, he states that two days ago he noticed

bloody sputum and this morning he noticed some chest pain when he exerted himself that lasted

for approximately 30 seconds. He states that he has had similar pain in the past. He states that he

has tried taking an OTC cough medication with little effect. The patient states that he has had no

nausea, vomiting, dizziness, or a headache. He reports that there has been no recent travel. 

However, he does mention that he has been visiting his wife regularly in the nursing home two to

three times a week. The patients past medical history includes hypertension (HTN), coronary

artery disease (CAD) with a coronary artery bypass graft (CABG), which he has gotten two

times five years ago, hyperlipidemia, and chronic obstructive pulmonary disease (COPD). In

terms of his current medical issues, he is being treated with Lisinopril 10 mg PO once daily,

Metoprolol 25 mg PO twice daily, Aspirin 325 mg PO once daily, Simvastatin 80 mg PO once

daily, Spiriva 18 mcg once daily, and an albuterol inhaler is available PRN. His surgical history

includes an appendectomy that was done in 1980. His social history contains no current alcohol

use and no drug use. Nonetheless he was a previous smoker for 50 years and was smoking one

pack a day. He did however quit smoking five years ago. 

Based on the information that was provided above, additional subjective data that is

important to collect from this patient include what makes the chest pain better and what makes

the chest pain worse, did he ever find out why he had that chest pain in the past, can he describe

the chest pain, can he rate the chest pain on a scale from 0 to 10 that he experienced, what did he

do for the chest pain to stop, does his chest feel tight, does he feel short of breath, does he have

difficulty breathing, does it hurt to breathe, has he ever had cold symptoms with a cough in the

past, how would he describe the cold symptoms that he has, how much bloody sputum is he
3
CASE STUDY

producing and how often, is the cough productive, what makes the cough better and what makes

the cough worse, does it hurt to cough, does he get frequent respiratory infections, how does he

feel right now, what OTC cough medication did he take, when did he take this OTC cough

medication, does he still take this OTC cough medication, does he take his list of medications as

prescribed, does he have any medical or environmental allergies, when was he diagnosed with

the list of diseases from his past medical history, when was the last time he checked his BP, how

often does he check his BP, when did his temperature start, when did he notice the pedal edema,

how long has his skin been clammy, any unexpected weight gain or weight loss, any loss of

appetite, any changes in his mental awareness, does he have any stressors, what is his support

system like, who does he live with, does he have transportation, what is his ethnicity, when was

the last time he went to visit his wife, has he had any exposure to TB, has he been around anyone

who is sick, are his immunizations up to date, when did he quit smoking and why, is he around

second hand smoke, does he drink alcohol, does he exercise, what is his families medical history,

when was his last hospital visit, and when was his last chest x-ray. Nonetheless, the patient

denies nausea/vomiting, dizziness, and headache. Other subjective questions to ask would be if

he feels fatigued, any chills, any diarrhea, and any night sweats (Shadow Health, 2021).

In terms of additional objective data that would be important to collect from this patient

would be the patients overall general appearance, oxygen saturation, weight, height, level of

consciousness, symmetry of chest, auscultated breath sounds, auscultated heart sounds,

auscultated carotid arteries, palpated lymph nodes, palpated arteries, palpated tactile fremitus,

percussion of chest wall, bronchophony, inspection of nasal cavity, inspection of mouth and

throat, inspection of neck, inspection of hands and fingernails, inspection of lower extremities

and toenails, and capillary refill time, (Shadow Health, 2021). Additionally, a chest x-ray should
4
CASE STUDY

be ordered, CBC, BMP, chemistry work up, spirometry (Singh, Avula, & Zahn, 2020), a

Mantoux test (Adigun & Singh, 2020), blood culture, sputum culture and microscopy, and

lymphocyte count. Special tests such as urinary antigen testing, bronchial aspirate, or induced

sputum may be done as well. Additionally, c-reactive protein, erythrocyte sedimentation rate,

procalcitonin levels, and a leucocyte count (Jain et al., 2021).

For this patient I have come up with three differential diagnoses which include

pneumonia, acute bronchitis, and tuberculosis (TB). First, pneumonia. Pneumonia, is an

infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus

(Pneumonia, 2020). There are different types of pneumonia such as community-acquired

pneumonia, hospital-acquired pneumonia, health care-acquired pneumonia, and aspiration

pneumonia (Pneumonia, 2020). Pneumonia can occur from bacteria, fungi, and viruses.

However, the most common cause is from bacteria (Pneumonia, 2020). Pneumonia can be mild

or life threatening, especially for people with health problems or weakened immune systems

(Pneumonia, 2020). With that being said, there are more risk factors that put certain people more

at risk of getting pneumonia such as being over the age of 65, being hospitalized, smoking,

having asthma, COPD, or heart disease (Pneumonia, 2020). In regards to symptoms, usually a

fever with chills, malaise, loss of appetite, and myalgias are seen (Jain et al., 2021). Clammy or

sweat skin is seen as well (What is the Difference Between Bronchitis and Pneumonia, 2020).

Additionally, there is a small chance that someone may have an altered mental status, abdominal

pain, and chest pain (Jain et al., 2021). Pulmonary findings such as a cough with or without

sputum production can be present (Jain et al., 2021). In terms of bacterial pneumonia, purulent or

blood-tinged sputum may also occur. Common findings during the physical examination that

may be seen are tachypnea, tachycardia, fever, decreased or bronchial breath sounds, crackles on
5
CASE STUDY

auscultation, and dullness during percussion (Jain et al., 2021). Wheezing is also a finding that

can be heard during auscultation (Wheezing, 2020). The rationale as to why this is one of the

three differential diagnoses is due to the patient reporting that he has cold symptoms with a

persistent cough, bloody sputum, chest pain, clammy skin, and a past history of smoking.

Additionally, during the examination he presented with a fever, tachypnea, tachycardia, and

expiratory wheezing bilaterally. Furthermore, he has also been visiting his wife regularly in the

nursing home two to three times a week.

Second, acute bronchitis. Acute bronchitis, which has also been referred to as a chest

cold, is when the lining of the bronchi is inflamed or in other words inflammation of the large

airways of the lung (Singh, Avula, & Zahn, 2020). The result of acute inflammation of the

bronchi is most commonly secondary to viruses. With that being said, this is sometimes caused

by allergens and bacteria. Additionally it can also be caused by irritants such as smoke

inhalation, polluted air inhalation and dust (Singh, Avula, & Zahn, 2020). In regards to

pathophysiology, with acute bronchitis the inflammation of the bronchial wall leads to mucosal

thickening, epithelial-cell desquamation, and denudation of the basement membrane.

Nonetheless, it is said that a viral upper respiratory infection can progress to an infection of the

lower respiratory tract resulting in acute bronchitis (Singh, Avula, & Zahn, 2020). It has been

said that having a history of smoking, living in a polluted place, crowding, and having a history

of asthma, are all risk factors for acute bronchitis (Singh, Avula, & Zahn, 2020). In terms of

diagnosing acute bronchitis, “there are no reliable diagnostic signs or laboratory tests, so the

diagnosis of acute bronchitis is essentially a clinical one” (Worrall, 2008). With that being said,

the most common symptom that would be seen is an acute cough that is usually productive. The

cough lasts for less than 3 weeks in about 50% of patients, however it can last for more than one
6
CASE STUDY

month in about 25% of patients as well (Worrall, 2008). Furthermore, blood in the sputum is also

common and seen with bronchitis (Silva, 2020). Additional symptoms that may be brought up

are fatigue, shortness of breath, fever and chills, and chest discomfort (Bronchitis, 2017). Also,

during a patients assessment signs of bronchial obstruction, such as wheezing or dyspnea on

exertion usually are present with bronchitis patients (Worrall, 2008). The rationale as to why

this is one of the three differential diagnoses is due to the patient reporting that he has cold

symptoms with a cough, bloody sputum and chest pain upon exertion. Additionally, during the

physical exam he presents with a fever of 101.2 and expiratory wheezing bilaterally.

Third, tuberculosis (TB). Tuberculosis (TB), is caused by a bacterium called

Mycobacterium tuberculosis. The bacteria usually attacks the lungs, however it can attack any

part of the body such as the kidney, spine, and brain (Tuberculosis, 2016). The bacteria that

cause TB are spread from person to person through tiny droplets that are released into the air

when coughing or sneezing (Tuberculosis, 2021). There are both Latent and Active tuberculosis.

Latent TB means the person has the TB infection, but the bacteria in the body is inactive and

causes no symptoms. This type of TB can turn into active TB which is why it is important to be

treated (Tuberculosis, 2021). Active TB is a condition that makes you sick and can spread to

others. This ca occur weeks or years after infection with TB bacteria (Tuberculosis, 2021). In

regards to risk factors for TB, these include having a weakened immune system, very young or

advanced age, traveling to areas with high TB rates, using IV drugs, excessive alcohol use,

tobacco, living or working in prisons, homeless shelters, nursing homes, and generally just being

in close contact with someone who has TB (Tuberculosis, 2021). Furthermore, symptoms for

TB include coughing for three or more weeks, coughing up blood or mucus, chest pain,

unintentional weight loss, fatigue, fever, night sweats, chills, loss of appetite (Tuberculosis,
7
CASE STUDY

2021). The rationale as to why this is one of the three differential diagnoses is due to his age,

cough, bloody sputum, and frequent visits to the nursing home to see his wife.

In regards to the plan for this patient, it would be most important to rule out any of the

differential diagnoses. However, with the information that has been provided, the patient seems

to be progressing further along and should be admitted to the hospital. This patient presents with

three out of the four criteria for systemic inflammatory response syndrome (SIRS). SIRS is

defined as “fulfilling at least two of the following four criteria: fever >38.0°C or hypothermia

<36.0°C, tachycardia >90 beats per minute, tachypnea >20 breaths per minute, leukocytosis

>12*109/l or leucopoenia <4*109/l (Comstedt, Storgaard, Lassen, 2009). With that being said,

this patient has a fever of 38.4°C which is greater than 38.0°C, a heart rate of 130 bpm which is

greater than 90 bpm, and his respirations are at 32 which is greater than 20 breaths per minute.

The last piece of criteria missing was not given, therefore it would be important to draw a CBC

in order to evaluate if he has leukocytosis or leucopenia (Comstedt, Storgaard, Lassen, 2009).

More so, the patient’s blood pressure is 90/54, therefore it would be important for the patient to

receive adequate resuscitation with intravenous fluids and if still hypotensive, vasopressor agents

should be administered with carefully hemodynamic monitoring (Burdette, 2017). Furthermore,

other tests to order would be blood cultures, urinalysis and culture, sputum gram stain and

culture, cardiac enzymes, amylase, lipase, cerebrospinal fluid analysis, liver profiles, lactate, and

venous or arterial blood gasses. These tests would be ordered because SIRS has such a high

mortality rate if not treated effectively (Boka, 2020). Additionally, “since effective treatment for

infection often requires bacteriologic identification of the inciting organism, priority for

bacteriological cultures in the diagnostic workup needs to be stressed” (Boka, 2020).

Unfortunately, there are no diagnostic imaging studies that exist for SIRS. However, “the
8
CASE STUDY

selection of imaging studies depends on the etiology that required hospital and intensive care unit

(ICU) admission” (Boka, 2020). Lastly, there is no drug of choice for treating SIRS (Burdette,

2017).

There are several complications that can occur from SIRS, with that being the follow up

for this patient should include routine prophylaxis, including deep vein thrombosis (DVT) and

stress ulcer prophylaxis (Boka, 2020). Additionally, “long-term antibiotics, when clinically

indicated, should be as narrow spectrum as possible to limit the potential for superinfection”

(Boka, 2020). In regards to education, it would be important to teach him the signs and

symptoms of SIRS so that if this were to ever happen again, he would know to go seek

immediate help. Furthermore, educating this patient that his age, underlying medical conditions

and weakened immune system put him at an increased risk for developing SIRS. In terms of

health promotion, it is important to remind the patient how important it is to wash your hands,

cover a cough, do not pick at healing wounds, do not share dishes/utensils/and glasses, and keep

up with adult vaccinations (How to prevent infections, n.d).

9
CASE STUDY

References

Adigun, R., & Singh, R. (2020). Tuberculosis. StatPearls. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK441916/

Boka, K. (2020). Systemic Inflammatory Response Syndrome (SIRS) Workup. Retrieved from

https://emedicine.medscape.com/article/168943-workup

Bronchitis. (2017). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-

conditions/bronchitis/symptoms-causes/syc-20355566

Burdette, S.D. (2017). Systemic Inflammatory Response Syndrome (SIRS). Antimicrobe.

Retrieved from

http://www.antimicrobe.org/e20.asp#:~:text=All%20patients%20should%20have%20ade

quate,not%20an%20indication%20for%20antibiotics.

Comstedt, P., Storgaard, M., & Lassen, A.T. (2009). The Systemic Inflammatory Response

Syndrome (SIRS) in acutely hospitalized medical patients: a cohort study. Doi:

10.1186/1757-7241-17-67

How to prevent infections. (n.d). Harvard Health Publishing. Retrieved from

https://www.health.harvard.edu/staying-healthy/how-to-prevent-infections

Jain, V., Vashisht, R., Yilmaz, G., & Bhardwaj, A. (2021). Pneumonia Pathology. StatPearls.

Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK526116/

Pneumonia. (2020). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-

10
CASE STUDY

conditions/pneumonia/symptoms-causes/syc-20354204

Shadow Health. (2021). An Elsevier Company. Retrieved from https://www.shadowhealth.com/

Silva, J.C. (2020). What causes blood in sputum? MedicalNews. Retrieved from

https://www.medicalnewstoday.com/articles/321563#:~:text=Blood%20in%20the%20sp

utum%20is,a%20lung%20or%20stomach%20condition.

Singh, A., Avula, A., Zahn, E. (2020). Acute Bronchitis. StatPearls. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK448067/

Tuberculosis. (2016). CDC. Retrieved from

https://www.cdc.gov/tb/topic/basics/default.htm#:~:text=Tuberculosis%20(TB)%20is%2

0caused%20by,with%20TB%20bacteria%20becomes%20sick.

Tuberculosis. (2021). Mayo Clinic. Retrieved from

https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-

20351250

What is the Difference Between Bronchitis and Pneumonia? (2020). Florida Medical Clinic.

Retrieved from https://www.floridamedicalclinic.com/blog/what-is-the-difference-

between-bronchitis-and-

pneumonia/#:~:text=Pneumonia%20may%20also%20cause%20confusion,the%20term%

20%E2%80%9CWalking%20Pneumonia%E2%80%9D.
11
CASE STUDY

Wheezing. (2020). Cleveland Clinic. Retrieved from

https://my.clevelandclinic.org/health/symptoms/15203-

wheezing#:~:text=Wheezing%20is%20the%20shrill%20whistle,pneumonia%2C%20hear

t%20failure%20and%20more.

Worrall, G. (2008). Acute Bronchitis. Canadian Family Physician. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2278319/