Case Presentation
Ms. Jones is a 67-year-old female who was 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 two days. Ms. Jones has a 30-pack per-year history of smoking cigarettes but quit smoking three years ago. Other known histories include 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 in the left side of her back and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately and has noticed 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 she 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
Allergies: Penicillin
Current Medications:
- Atorvastatin 40mg p.o. daily
- Multivitamin 1 tablet daily
- Losartan 50mg p.o. daily
- ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
- Caltrate 600mg+ D3 1 tablet daily
Diagnosis: Pneumonia
Albumin 3.4to 5.4 g/dL (34 to 54 g/L)
Alkaline phosphatase 44 to 147 IU/L (0.73 to 2.45 µkat/ L)
ALT (alanine aminotransferase) 7 to 40 IU/L (0.12 to 0.67 µkat/ L)
AST (aspartate aminotransferase) 10 to 34 IU/L (0.17 to 0.57 µkat/ L)
BUN (blood urea nitrogen) 6 to 20 mg/dL (2.14 to 7.14 mmol/L)
Calcium 8.5 to 10.2 mg/dL (2.13 to 2.55 mmol/L)
Chloride 96 to 106 mEq/L (96 to 106 mmol/L)
CO2 (carbon dioxide) 23 to 29 mEq/L (23 to 29 mmol/L)
Creatinine* 0.6 to 1.3 mg/dL (53 to 114.9 µmol/ L)
Glucose 70 to 100 mg/dL (3.9 to 5.6 mmol/L)
Potassium 3.7 to 5.2 mEq/L (3.70 to 5.20 mmol/L)
NA 135 to 145 mEq/L (135 to 145 mmol/L)
Total bilirubin 0.3 to 1.9 mg/dL (5.0 to 32.5 µmol/ L)
Total protein 6.0 to 8.3 g/dL (60 to 83 g/L)
*Normal results for creatinine can differ with age.
Findings to Be Seen on the Chest X-Ray Results
Pneumonia is a lung infection with chest pain while coughing, fatigue, fever, and shortness of breath. There are two main types of pneumonia, viral and bacterial pneumonia, although their patterns during X-ray are the same. Pneumonia makes it difficult for oxygen to move freely, hence causing breathing difficulties. Mostly, it affects children who are five years and below, people who are around 65 years and older, people who have existing health conditions such as diabetes, asthma, and heart diseases, and those who smoke.
An X-ray was conducted for Ms. Jones, and the expected findings include crackles, lung inflation, chest pains, breathing problems, elevated heart rate, and rhinorrhea. This condition occurs when a provoking substance enters the tiny alveoli and blocks them, causing the lungs to swell (Liang et al., 2017). Another noticeable sign is that the doctors found the alveoli or air sacs filled with liquids (Ohashi et al., 2019). The fact that alveoli were blocked and also filled with liquid is the main reason why Ms. Jones had difficulty breathing since the air could not move freely in her lungs.
Defining Type of Pneumonia
Hospital-acquired pneumonia (HAP) occurs around two or more days after a patient has been admitted and is usually not present during the hospital admission day. On the other hand, community-acquired pneumonia (CAP) is contracted mainly by people living in crowded places such as schools and colleges (Lanks et al., 2019). HAP is mainly linked to existing lung diseases, suctioning, or asthma, while the most hazardous factors for CAP are mostly smoking, conditions like COPD, chronic diseases, cardiovascular diseases, and alcoholism. Of these two, CAP is the leading in mortality rates.
Ms. Jones has Chronic Obstructive Pulmonary disease (COPD), vitamin D deficiency, hypertension, and hyperlipidemia and has been smoking for the last thirty years, so she has CAP. CAP can result from exposure to germs such as bacteria and fungi, but Ms. Jones contracted hers through smoking. The smoke entered the lungs and blocked the tiny air sacs, hindering oxygen’s normal movement through the alveoli and bloodstream (Wintenberger et al., 2017). Also, Ms. Jones’s condition became more complicated due to her existing conditions.
Determining the Severity of Pneumonia
Scientists have not yet found the best tool to check the severity of pneumonia at an early stage but have discovered others that are already in use and of help. The Pneumonia Severity Index (PSI) is an assessment tool that determines the severity of pneumonia (Lane et al., 2019). It measures on a scale of 1-5, where 0-1 shows that it is mild, whereas two and above are associated with moderate or severe. It classifies the severity of the disease into mild, moderate, and severe to enable the doctors to deal with it according to its extent (Wahyuni & Ramadhan, 2019). Treatment options would be administering a cough medicine, which would ease the pain. Using antibiotics would help the patient feel better, and painkillers and fever reducers would take away the discomfort and fever.
The tool to be applied is PSI if there could have the client’s Ph and PO2 levels are known in this case study. Devoid of such information, the most suitable tool is CURB-65. Utilizing CURB-65, the case would have the following results: respiratory Rate >28/min, confusion (No=0), Urea (BUN >18, No=0), (No=0), Systolic, diastolic BP Age > 64 (Yes=1). The score obtained by Ms Jones is one, and she is awake and alert. The vital signs are stable, with a respiratory rate of 24/min and BO of 130/8. Blood nitrogen and urea are within normal ranges, showing a low risk of hypertension. Upon examination, it was reviewed that age is a major risk factor. This indicates that the patient can receive care in outpatient settings.
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?
The left lower lobe is mainly caused by a bacteria called streptococcus pneumonia, which sometimes occurs on its own after catching a cold or flu. It brings about fatigue, chest pain when one coughs, fever, nausea, mucus discharge after coughing, and sometimes mental problems for the elderly. Ms. Jones has underlying conditions like penicillin allergy, and penicillin is an antibiotic (Rodriguez et al., 2017). She has also been misusing her inhaler for some time now, which means she has a weaker immune system, terrible synonyms, and more visits to healthcare centers. As a result, I would use short-term antibiotics to prevent more harm. Normally, antibiotics are administered for a maximum of 2 weeks. However, for people with the same condition as Ms. Jones, I would give her antibiotics that last for a maximum of one week (Casey, 2019). I would use levofloxacin and azithromycin since they do not heal completely as they are meant to give the body bacterial resistance.
I would also utilize macrolide, which is used to treat patients with conditions related to bacteria. Macrolide is a good option because it does not contain penicillin, which Ms. Jones is allergic to (Criner et al., 2019). Oxygen therapy would be of great help to Ms. Jones because it involves getting external sources of oxygen supply, which the patient is lacking due to blockage of her air sacs. Oral rehydration therapy would also help cure her because moisture is used on the patient to avoid dehydration.
The Gold Standard for Measuring Airflow Limitation
The gold standard for measuring airflow limitation of COPD is spirometry, which is believed to be accurate enough for measuring lung function (Khatri et al., 2017). The accuracy of spirometry enables doctors to ignite more suitable treatment. COPD is deadly, and its damage to the lungs cannot be solved. Chronic bronchitis and emphysema are the leading conditions that contribute to COPD (Singh et al., 2021). Its symptoms include coughing, which might be dry, or with a mucus discharge called phlegm. The patient also experiences fatigue and respiratory infections, which make breathing even harder.
Differentials for Initial Presentation
There is a higher chance that Ms. Jones might have contracted the following disease: Tuberculosis (TB), which developed due to smoking and is characterized by severe coughs (Anis et al., 2019). Diabetes is also caused by smoking and is characterized by fatigue. Chronic respiratory diseases originate from smoking and are characterized by fatigue and body weakness because there is no proper oxygen circulation.
Patient Education and Follow-Up Instructions
I would advise Ms. Jones to take the medication as directed to avoid coming for regular checkups. Her daughter Susan ensured her mother took medicine as prescribed without overdosing (Noguchi et al., 2017). I would ask her to ensure that she gets a total rest and avoid engaging in normal house duties until she feels better. She should also try to walk a little to improve the condition of her leg.
I would ask her to make sure she tries every possible way to get rid of her cough so that she can comfortably (Rodriguez et al., 2017). Avoiding dehydration and drinking fluids frequently would be important and help her heal quicker. I would ask Susan to ensure her mother checks on her diet and eats healthy foods to enable the body to resist infections and to find a caregiver for her mother.
Treatment Options for Pneumonia
Both amoxicillin and macrolide are used for patients with bacterial infections such as pneumonia, but amoxicillin contains penicillin, while macrolide does not. This means that amoxicillin cannot be used alone in Ms. Jones’s case because she is allergic to penicillin (Sodhi et al., 2021). Therefore, a combination of these two can be used, or the macrolide can be used alone without amoxicillin. Ms. Jones should use these drugs for a short period to avoid causing more harm than good and avoid taking penicillin to keep her immune safe. Continued consumption of drugs with penicillin for a long time can be harmful to her because she is allergic to penicillin.
Albumin 3.4to 5.4 g/dL (34 to 54 g/L)
Alkaline phosphatase 44 to 147 IU/L (0.73 to 2.45 µkat/ L)
ALT (alanine aminotransferase) 7 to 40 IU/L (0.12 to 0.67 µkat/ L)
AST (aspartate aminotransferase) 10 to 34 IU/L (0.17 to 0.57 µkat/ L)
BUN (blood urea nitrogen) 6 to 20 mg/dL (2.14 to 7.14 mmol/L)
Calcium 8.5 to 10.2 mg/dL (2.13 to 2.55 mmol/L)
Chloride 96 to 106 mEq/L (96 to 106 mmol/L)
CO2 (carbon dioxide) 23 to 29 mEq/L (23 to 29 mmol/L)
Creatinine* 0.6 to 1.3 mg/dL (53 to 114.9 µmol/ L)
Glucose 70 to 100 mg/dL (3.9 to 5.6 mmol/L)
Potassium 3.7 to 5.2 mEq/L (3.70 to 5.20 mmol/L)
NA 135 to 145 mEq/L (135 to 145 mmol/L)
Total bilirubin 0.3 to 1.9 mg/dL (5.0 to 32.5 µmol/ L)
Total protein 6.0 to 8.3 g/dL (60 to 83 g/L)
*Normal results for creatinine can differ with age.
References
Anis, K. H., Weinrauch, L. A., & D’Elia, J. A. (2019). Effects of smoking on solid organ transplantation outcomes. The American Journal of Medicine, 132(4), 413-419. Web.
Bartley, P., Deshpande, A., Yu, P. C., Haessler, S., Zilberberg, M., Imrey, P.,… & Rothberg, M. (2019). 2793. Influenza and bacterial pneumonia Coinfection: Rates and outcomes. In Open Forum Infectious Diseases (Vol. 6). Web.
Casey, S., Lanting, S., Oldmeadow, C., & Chuter, V. (2019). The reliability of the ankle brachial index: a systematic review. Journal of Foot and Ankle Research, 12(1), 1-10. Web.
Criner, G. J., Martinez, F. J., Aaron, S., Agusti, A., Anzueto, A., Bafadhel, M.,… & Celli, B. R. (2019). Current controversies in chronic obstructive pulmonary disease. A report from the Global Initiative for Chronic Obstructive Lung Disease Scientific Committee. Annals of the American Thoracic Society, 16(1), 29-39. Web.
Khatri, A., Jain, R., Vashista, H., Mittal, N., Ranjan, P., & Janardhanan, R. (2020). Pneumonia identification in chest X-ray images using EMD: Trends in Communication, Cloud, and Big Data, 87-98. Web.
Lane, R., Harwood, A., Watson, L., & Leng, G. C. (2017). Exercise for intermittent claudication. Cochrane Database of Systematic Reviews, (12). Web.