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Pulmonary Case StudyDavid CoxMaryville UniversityPulmonary Case StudyBasic InformationSite: FloorService: HospitalistDate of Admission: 9/1/18Patient Initials: XYSubjective HistoryCC: “Trouble breathing this morning”HPIXY is an 84 y/o M with a PMH of HTN, BPH and seasonal allergies, presenting to the ED today for trouble breathing. He states that yesterday he developed a productive cough with yellow sputum. This morning he states that he developed shortness of breath and asked his wife to drive him to the ED. He also reports feeling fatigued. In the ED his O2 saturation was noted to be 89% on RA and his temperature was 99.3.Additional questions:Have you taken anything for your cough?Do you have any associated symptoms with your shortness of breath?Do you have any history of COPD?Does anything make your SOB worse?Does anything improve your SOB?Have you been around anyone sick recently?Any recent travel?How long have you had an elevated temperature?Do you have any night sweats?PMHx: HTNSeasonal allergiesBPHAdditional Assessment: Inquire if patient takes aspirin for a medical condition other than HTN.Current Meds: metoprolol 25 mg po qdaspirin 81 mg po qdclaritin prnAdditional Assessment: Clarify Claritin dosage and frequency. Inquire why patient is taking ASA. Ask about any possible recent antibiotic usage.Med Allergies:NKDAAdditional Assessment: Verify that the patient has no drug allergies, and if so, what reactions/severity were experienced.PSHx:Cataract removal last yearCholecystectomy 20 years agoAdditional Assessment: Verify this is a thorough PSH and that the patient has not had any other surgical procedures.Social hx: Tobacco: denies.Alcohol: reports drinks once per weekIllicit drug use: denies.Additional Assessment: Inquire about previous cigarette usage. Ask how many drink equivalents patient has when he drinks.Family hx: Non-contributoryAdditional Assessment: Inquire if patient is up to date on influenza and pneumonia vaccines.ROSCONSTITUTIONAL: FATIGUEEyesENTRESPIRATORY: REPORTS COUGH, SHORTNESS OF BREATH, TACHYPNEACardiovascularGIGUMusculoskeletalNeuroPsychAdditional questions:Any fevers?Any chills?Any chest pain?Any myalgias?Any malaise?Any nausea, vomiting, or diarrhea?Any dizziness?Any syncope?Any palpitations?Objective AssessmentVitals: B/P 124/80, T: 99.3F, HR: 96, RR 22, SpO2: 89% RABedside monitoring data: none availableCritical care support settings: none availablePhysical exam:Constitutional: answers questions without difficultyEyesENMTNeckCardiovascular: RRR, S1, S2, borderline tachycardiaRESPIRATORY: MILD TACHYPNEA, lungs CTA bilaterally on RA, even respirationsGIIntegumentaryNeurologic: A&Ox3PsychAdditional Assessments:Any vocal or tactile fremitus, egophony, or bronchophony?Any percussion dullness?Any cyanosis?Any diminished breath sounds?Any URI symptoms?Any edema?Any lymphadenopathy?Labs: CBC with white blood cell countLactic acidArterial blood gas (ABG)Blood culturesSputum culturesRespiratory virus panelDiagnostic Tests:Chest x-rayAssessmentDiscussionThis is an 84 y/o M with symptoms concerning for PNA such as fever, fatigue, tachypnea, cough with sputum, shortness of breath, and hypoxemia. Patient comes from home with no recent hospital stay, making this a suspected CAP. Additional testing is pending to rule out other diagnoses and confirm PNA. Waiting on results of ABG to grade severity of hypoxemia but may be moderate considering spO2 of 89% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5XgF47pL","properties":{"formattedCitation":"(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017)","plainCitation":"(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017)","noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}},{"id":106,"uris":[""],"uri":[""],"itemData":{"id":106,"type":"book","title":"Current medical diagnosis & treatment 2018","publisher":"McGraw-Hill","publisher-place":"United States","edition":"57","event-place":"United States","ISBN":"978-1-259-86148-2","editor":[{"family":"Papadakis","given":"M. A."},{"family":"McPhwee","given":"S. J."}],"issued":{"date-parts":[["2018"]]}}},{"id":102,"uris":[""],"uri":[""],"itemData":{"id":102,"type":"webpage","title":"Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care - UpToDate","URL":"","author":[{"family":"Yealy","given":"Donald M"},{"family":"Fine","given":"Michael J"}],"issued":{"date-parts":[["2017"]]},"accessed":{"date-parts":[["2018",9,1]]}}}],"schema":""} (Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017).Differential Diagnoses:Community acquired pneumoniaBronchitisAcute COPD exacerbationUpper respiratory infectionHeart failureAllergic rhinitisPulmonary embolismPlural effusionTuberculosisInfluenza ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NQ6RZJ8I","properties":{"formattedCitation":"(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017)","plainCitation":"(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017)","noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}},{"id":106,"uris":[""],"uri":[""],"itemData":{"id":106,"type":"book","title":"Current medical diagnosis & treatment 2018","publisher":"McGraw-Hill","publisher-place":"United States","edition":"57","event-place":"United States","ISBN":"978-1-259-86148-2","editor":[{"family":"Papadakis","given":"M. A."},{"family":"McPhwee","given":"S. J."}],"issued":{"date-parts":[["2018"]]}}},{"id":102,"uris":[""],"uri":[""],"itemData":{"id":102,"type":"webpage","title":"Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care - UpToDate","URL":"","author":[{"family":"Yealy","given":"Donald M"},{"family":"Fine","given":"Michael J"}],"issued":{"date-parts":[["2017"]]},"accessed":{"date-parts":[["2018",9,1]]}}}],"schema":""} (Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017).Problem List and Management PlanAcute hypoxemia with suspected CAPAdmit to inpatient floorTitrate supplemental O2 to maintain O2 saturation > 92%Aggressive pulmonary hygiene including frequent incentive spirometry use.STAT ABGsSTAT CXRSTAT blood culturesStart empiric antibiotic coverage for suspected CAP: Ampicillin-sulbactam 1.5mg Q6 IV, Azithromycin 500mg IV daily. Will observe for improvement over the course of 48 hours and if no improvement consider changing antibiotics and adding vancomycin for Methicillin-resistant Staphylococcus aureus?(MRSA) coverageStart Guaifenesin 1200mg PO Q6HTN, controlled.Continue metoprolol 25mg PO BIDContinue ASA 81mg PO dailySeasonal allergiesContinue Claritin PRN (clarify dosage)FEN: Bedside swallow evaluation to rule out aspiration. If pass: start regular diet, saline lock IV. If fail: make NPO, call provider for IVF orders.DVT prophylaxis: ?SCDsFollow up plan: Will be followed daily by the hospitalist service. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nb20ZoGG","properties":{"formattedCitation":"(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017)","plainCitation":"(Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017)","noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}},{"id":106,"uris":[""],"uri":[""],"itemData":{"id":106,"type":"book","title":"Current medical diagnosis & treatment 2018","publisher":"McGraw-Hill","publisher-place":"United States","edition":"57","event-place":"United States","ISBN":"978-1-259-86148-2","editor":[{"family":"Papadakis","given":"M. A."},{"family":"McPhwee","given":"S. J."}],"issued":{"date-parts":[["2018"]]}}},{"id":102,"uris":[""],"uri":[""],"itemData":{"id":102,"type":"webpage","title":"Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care - UpToDate","URL":"","author":[{"family":"Yealy","given":"Donald M"},{"family":"Fine","given":"Michael J"}],"issued":{"date-parts":[["2017"]]},"accessed":{"date-parts":[["2018",9,1]]}}}],"schema":""} (Bartlett, 2018; Papadakis & McPhwee, 2018; Yealy & Fine, 2017).Patient Education:Inform patient on need for admission based on hypoxemia and need to treat suspected CAP.Case AnalysisThe patient presented with symptoms of a cough with yellow sputum, shortness of breath, hypoxemia, low grade temperature, mild tachypnea, borderline tachycardia, and fatigue. Per ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"N5VL4wTU","properties":{"formattedCitation":"(Bartlett, 2018)","plainCitation":"(Bartlett, 2018)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} Bartlett (2018), these symptoms are suggestive of pneumonia, and considering that the patient lives at home, this would be considered a community acquired pneumonia (CAP). Bartlett also states that additional typical findings of a CAP include pleuritic chest pain, as well as nausea, vomiting, diarrhea, chills, and rigors, so these items would be inquired about in the history of present illness, review of systems, and physical examination. I would also inquire if the patient were around any sick individuals or has had any issues swallowing (aspiration) that may point towards an etiology ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JeBqrZBC","properties":{"formattedCitation":"(Bartlett, 2018)","plainCitation":"(Bartlett, 2018)","noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} (Bartlett, 2018). Upon examination of the chest x-ray (CXR) results of patients with a CAP, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"88GzfELQ","properties":{"formattedCitation":"(Bartlett, 2018)","plainCitation":"(Bartlett, 2018)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} Bartlett (2018) states that infiltrates are a typical finding. Additionally, Bartlett states that consolidation in the lobes is another frequent finding of CAP, and that there may or may not be cavitation present. Bartlett also states that the radiograph should be a minimum of two views, and that a CXR is typically sufficient in diagnosing pneumonia without the need for a computed tomography (CT) scan, although such a test can clarify an ambiguous CXR image ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HcNa7mqk","properties":{"formattedCitation":"(Bartlett, 2018)","plainCitation":"(Bartlett, 2018)","noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} (Bartlett, 2018). According to ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ArUCQd0Z","properties":{"formattedCitation":"(Papadakis & McPhwee, 2018)","plainCitation":"(Papadakis & McPhwee, 2018)","noteIndex":0},"citationItems":[{"id":106,"uris":[""],"uri":[""],"itemData":{"id":106,"type":"book","title":"Current medical diagnosis & treatment 2018","publisher":"McGraw-Hill","publisher-place":"United States","edition":"57","event-place":"United States","ISBN":"978-1-259-86148-2","editor":[{"family":"Papadakis","given":"M. A."},{"family":"McPhwee","given":"S. J."}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} Papadakis and McPhwee (2018), a pulmonary opacity is required to create a diagnosis of CAP on a CXR.Upon examination of the patient’s AGBs, I would expect to find respiratory alkalosis. Theodore (2017) states that the most common cause of respiratory alkalosis is hyperventilation. Given that the patient is slightly tachypneic and likely compensating for being hypoxemic, he could be lowering his carbon dioxide level through overexcretion in the alveoli of the lungs ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Px36sYLS","properties":{"formattedCitation":"(Theodore, 2017)","plainCitation":"(Theodore, 2017)","noteIndex":0},"citationItems":[{"id":107,"uris":[""],"uri":[""],"itemData":{"id":107,"type":"article-journal","title":"Arterial blood gases","container-title":"UpToDate","URL":"","author":[{"family":"Theodore","given":"A. C."}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} (Theodore, 2017). As to whether or not his gases are compensated is unknown, but if it were compensated then he would have an elevated bicarbonate level ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0KgLb08o","properties":{"formattedCitation":"(Theodore, 2017)","plainCitation":"(Theodore, 2017)","noteIndex":0},"citationItems":[{"id":107,"uris":[""],"uri":[""],"itemData":{"id":107,"type":"article-journal","title":"Arterial blood gases","container-title":"UpToDate","URL":"","author":[{"family":"Theodore","given":"A. C."}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} (Theodore, 2017). The patient’s partial pressure of oxygen (paO2) level is likely low given the spO2 of 89% on room air, and according to the oxyhemoglobin dissociation curve, it is possible that he is moderately hypoxemic with a paO2 of under 60 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"diHMT0ra","properties":{"formattedCitation":"(Papadakis & McPhwee, 2018; Theodore, 2017; UpToDate, 2018)","plainCitation":"(Papadakis & McPhwee, 2018; Theodore, 2017; UpToDate, 2018)","noteIndex":0},"citationItems":[{"id":106,"uris":[""],"uri":[""],"itemData":{"id":106,"type":"book","title":"Current medical diagnosis & treatment 2018","publisher":"McGraw-Hill","publisher-place":"United States","edition":"57","event-place":"United States","ISBN":"978-1-259-86148-2","editor":[{"family":"Papadakis","given":"M. A."},{"family":"McPhwee","given":"S. J."}],"issued":{"date-parts":[["2018"]]}}},{"id":107,"uris":[""],"uri":[""],"itemData":{"id":107,"type":"article-journal","title":"Arterial blood gases","container-title":"UpToDate","URL":"","author":[{"family":"Theodore","given":"A. C."}],"issued":{"date-parts":[["2017"]]}}},{"id":108,"uris":[""],"uri":[""],"itemData":{"id":108,"type":"webpage","title":"Hemoglobin oxygen dissociation curve","URL":"","author":[{"literal":"UpToDate"}],"issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2018",9,5]]}}}],"schema":""} (Papadakis & McPhwee, 2018; Theodore, 2017; UpToDate, 2018).Per ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NfJsIOZB","properties":{"formattedCitation":"(Yealy & Fine, 2017)","plainCitation":"(Yealy & Fine, 2017)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":102,"uris":[""],"uri":[""],"itemData":{"id":102,"type":"webpage","title":"Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care - UpToDate","URL":"","author":[{"family":"Yealy","given":"Donald M"},{"family":"Fine","given":"Michael J"}],"issued":{"date-parts":[["2017"]]},"accessed":{"date-parts":[["2018",9,1]]}}}],"schema":""} Yealy and Fine (2017), there is a tool called the community acquired pneumonia severity index (PSI) which can assist providers in determining whether or not to admit patients for a CAP. The index places patients in classes with class I being associated with the lowest mortality, and class V being associated with the highest mortality. The creators of the tool state that patients in classes I-III may be treated outpatient, but that IV and V should be admitted for treatment, particularly in cases of hypoxemia. Per the PSI calculator provided by ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"udmY9JPg","properties":{"formattedCitation":"(UpToDate, n.d.)","plainCitation":"(UpToDate, n.d.)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":100,"uris":[""],"uri":[""],"itemData":{"id":100,"type":"webpage","title":"Calculator: Community-acquired pneumonia severity index (PSI) for adults","URL":"","author":[{"literal":"UpToDate"}],"accessed":{"date-parts":[["2018",9,1]]}}}],"schema":""} UpToDate (n.d.), the patient in this case study is deemed a class IV with a score of 94 and should therefore be admitted to the hospital. This score was due to the patient’s advanced age and hypoxemia.The patient is without medication allergies and considering his hypoxemia he is at an increased mortality risk according to the previously mentioned PSI calculator. Per ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"yp0MEm04","properties":{"formattedCitation":"(Bartlett, 2018)","plainCitation":"(Bartlett, 2018)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"Diagnostic approach to community-acquired pneumonia in adults","container-title":"UpToDate","URL":"","author":[{"family":"Bartlett","given":"John G"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} Bartlett (2018), the presence of colored sputum is more often associated with bacterial pneumonia versus viral. Therefore, his treatment should include empiric antibiotic coverage. According to ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xSs7auyE","properties":{"formattedCitation":"(File, 2018)","plainCitation":"(File, 2018)","noteIndex":0},"citationItems":[{"id":104,"uris":[""],"uri":[""],"itemData":{"id":104,"type":"webpage","title":"Treatment of community-acquired pneumonia in adults who require hospitalization","URL":"","author":[{"family":"File","given":"Thomas M"}],"issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2018",9,1]]}}}],"schema":""} File (2018), the patient is without risk factors for pseudomonas or antibiotic resistance due to no stated recent antibiotic use, recent hospitalizations, or high risk living situations. For this type of patient, File recommends a combination treatment with a beta-lactam and a macrolide such as ampicillin-sulbactam and azithromycin ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Y0BSdh3d","properties":{"formattedCitation":"(File, 2018)","plainCitation":"(File, 2018)","noteIndex":0},"citationItems":[{"id":104,"uris":[""],"uri":[""],"itemData":{"id":104,"type":"webpage","title":"Treatment of community-acquired pneumonia in adults who require hospitalization","URL":"","author":[{"family":"File","given":"Thomas M"}],"issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2018",9,1]]}}}],"schema":""} (File, 2018).References ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Bartlett, J. G. (2018). Diagnostic approach to community-acquired pneumonia in adults. UpToDate. Retrieved from , T. M. (2018). Treatment of community-acquired pneumonia in adults who require hospitalization. Retrieved September 1, 2018, from , M. A., & McPhwee, S. J. (Eds.). (2018). Current medical diagnosis & treatment 2018 (57th ed.). United States: McGraw-Hill.Theodore, A. C. (2017). Arterial blood gases. UpToDate. Retrieved from . (2018). Hemoglobin oxygen dissociation curve. Retrieved September 5, 2018, from . (n.d.). Calculator: Community-acquired pneumonia severity index (PSI) for adults. Retrieved September 1, 2018, from , D. M., & Fine, M. J. (2017). Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care - UpToDate. Retrieved September 1, 2018, from ................
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