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Ann Luna11/10/2013Dr. JuneauDate of Encounter: 11/8/2013Location of Encounter: St. Vincent’s ClinicIdentifying Information: BW, 42 years old, Male, White(S) SubjectiveChief ComplaintPatient c/o of a “fever lasting 3 days” and nausea and cough lasting the past 2 days.History of Present IllnessPatient’s symptoms began, suddenly, 3 days ago during the day at work. His nausea and cough started, gradually, during the last 2 days. Patient’s nausea is intermittent and exacerbated with increased activity, and his cough lasts all day and at night. His symptom of fever is intermittent, worsening at night. Before bed, patient has highest fever and has had a temperature maximum of 103F. His cough is dry with no mucus production or excretion. Associated symptoms include clear nasal congestion, sore throat, night sweats, fatigue, and headache. Patient states he has had an unintentional weight loss of 5 pounds in the past week. Patient says aggravating factors include noises and activity, which worsen his fatigue. Alleviating factors include rest with ibuprofen and mucinex, which he has been taking over the counter for the past 3 days. No one in patient’s home has been sick. BW denies diarrhea, constipation, abdominal pain, chest pain, SOB, and wheezing. Current Health Status-No known drug or food allergies-No medications regularly taken; No current health problems-Immunizations are up to date. Patient did receive his influenza virus vaccine this year.-Patient admits to tobacco smoking, .5 packs per day for past 10 years. No drug, alcohol, or caffeine use.-Patient’s last physical exam 9/2013. Noted no note of hernia or testicular masses upon examination. Does he practice Self Testicular exams?-Patient eats fast food 4-5 times per week and has a healthy appetite.-Patient exercises regularly.Relevant Past Medical History-Patient has no history of surgeries, hospitalizations, or blood transfusions.-Patient broke his left arm in 2008, and he has no other accident/injuries/fractures.-Patient has a history of recurrent strep throat as a child. No History of Asthma, Allergies, or COPD.-Patient has not experienced any obstacles in preforming his ADL.Social HistoryPatient lives with his girlfriend in a single bedroom apartment in Galveston, Texas. He works full time for a construction company and is outdoors a lot. He has two children who live with their mom in Dickinson, Texas. He is concerned with his finances, but BW makes enough money to pay bills and live frugally. He does not attend church regularly and has no military history.Patient’s Explanatory ModelPatient believes he has a strep throat infection with more malaise and fever. He would like relief from his nausea and fatigue. He’s had to miss 2 days of work, and would like to be able to stay home until his symptoms have resolved. He has no underlying fear associated with his condition.Family HistoryPatient’s mother is 65 years old and living with adult-onset hypertension controlled with medication. Patient’s father is 66 years old and overweight with hypertension. Patient’s children area alive and healthy with no significant medical conditions. Patient has no siblings.ROS of Relevant Symptoms-General: Positive: lethargy, weakness, night sweats, unintentional weight loss of 5 pounds in past week, and fever -Skin: Negative: skin rashes or other notable skin conditions related to chief complaint-Head and neck: Negative: swollen or tender lymph nodes-Eyes: Negative: excess eye drainage, irritation, or changes in vision-Ears: Negative: change in hearing, discharge, vertigo, tinnitus, or pain-Nose: Positive: nasal congestion -Throat and Mouth: Positive: sore throat-CV: Negative: Hypertension and heart problem Patient has not had an EKG.-Chest/Lungs: Positive: cough with yellow exudate throughout the day Negative: wheezing and SOB(O) ObjectiveGeneral Description/Physical Exam-42 year old male, alert and oriented X3, clean, well kept, and speaks appropriately for his age. Patient is in no apparent acute distress, but he does appear fatigue. Temp: 99.4, HR 92, Respiratory Rate: 14, BP: 104/70, O2 sats 98% Height: 5’8 Weight: 155 pounds.-Head: Normocephalic, no masses, lesions, or depressions. Appropriate hair distribution and color. No tenderness noted upon palpation of facial sinuses. -Eyes: PERRLA, clear conjunctiva-ENT: Tympanic membrane pink, with landmarks noted; Clear nasal discharge noted, Nasal turbinate non erythematous and non swollen; Throat erythematous with no swelling or exudate present.-Respiratory: Diminished breath sounds in left lower quadrant, symmetrical chest expansion. Positive for fine crackles, cleared with coughing.-Cardiovascular: Regular rate and rhythm, no gallops, rubs, clicks, or murmurs. No significant JVD present. Peripheral pulses +2, extremities warm and dry, and capillary refill <3 seconds.-Abdomen: Soft, non-tender, non-distended, bowel sounds present in all quadrants. No hepatomegaly noted. -Skin: Elastic skin turgor, no rashes, clubbing, lesions, cyanosis, or other skin abnormalities present.(A) AssessmentMedical Diagnosis:PneumoniaRationale: Positive findings include history of URI, smoking, diminished breath sounds, chills, fever, fatigue, and productive cough (Hollier, 2011, pp. 596-602).Differential Diagnoses:Influenza VirusRationale: Positive findings include fever running greater 101F (103F), sudden fatigue and malaise, cough, and headache (Dunphy, 2011, pp. 335-338). Group A Streptococcus pharyngitisRationale: Positive findings include chills, fever, and sore throat. Patient also has a history of recurrent strep throat infections (Dunphy, 2011, pp. 314-316).(P) PlanDiagnostic Tests;1) Flu ScreeningRationale: May rule out or in the possibility of a flu infection (Hollier, 2011).Result: Negative2) Rapid Strep TestRationale: May rule out or in the possibility of a strep throat infection (Hollier, 2011).Result: Negative3) CBC with DifferentialRationale: May rule out or in possible infectious process (Hollier, 2011, pp. 598).Results: Send out lab4) Chest X RayRationale: Show whether infiltrates are present upon PA and lateral X-Ray. The presence of an infiltrate is considered the gold standard for diagnosis of pneumonia (Hollier, 2011, pp. 598). Results: Positive for left lower infiltrate.Pharmacotherapeutics-Azithromycin 500mg day one, then 250mg daily for four days (Hollier, 2011) The study of Fluoroquinolones versus Macrolides was done without regard to randomized, controlled trials (File, 2013). -Instruct patient alternate between 325 mg Tylenol and 200-400 mg Ibuprofen every 4-6 hours for fever and aches. Keep fever <100.4F (Dunphy, 2011). Education-Smoking cessation with the 5 A’s. -Instruct patient to wash hands frequently and avoid touching face or mucosal membranes.-Instruct patent to get plenty of rest, fluids, and control of fever.-Instruct patient not to return to work for 1 week, or after all symptoms are resolved. -When taking Azithromycin, avoid concomitant use of aluminum or magnesium containing antacids.-Patient should begin to notice improvement in condition after 24-72 hours of antibiotic initiation. Follow Up CareFollow up with provider within 24-72 hours after initiating antibiotic therapy (Hollier, 2011). Perform follow up chest x-ray in 4-6 weeks after treatment completion of antibiotics (Hollier, 2011). If patient develops symptoms such as severe weakness, SOB, worsening lethargy/fatigue, unresponsiveness, or extreme elevation in temperature, call 911 immediately or go to the nearest Emergency CenterRationale for Plan of Care -1Research Article Analysis on Community Acquired Pneumonia (CAP) Empirical Antibiotic Treatment:A 1996 meta-analysis of 127 studies with 33,000 patients with pneumonia found the mortality rate from 5.1% to 13.6% in hospitalized patients and 36.5% in intensive care admitted patients. CAP is an acute infection of the pulmonary parenchyma with the acquired infection obtained from the community (File, 2013). Antibiotic therapy is usually started empirically since the organism is not identified in most outpatient settings. A sputum Gram stain can direct the choice of initial therapy. Clinical signs and symptoms and chest x rays are not specific enough to determine etiology (File, 2013). In 2007, the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) determined guidelines for the management of outpatient CAP. Recommendations are based on low rate of failure in patients with CAP. A study used over 700 ambulatory patients treated for CAP in one of six emergency departments seen from November 2000 to April 2001. In this study, empiric antibiotics (a macrolide or fluoroquinolone in more than 88%) were universally effective (File, 2013). Only 2.2 percent needed hospitalization within 3 weeks of their initial emergency department visit. The use of empirical antibiotic treatment is contingent upon 4 major factors: the most likely or common pathogen, clinical trials proving efficacy, risk factors for antimicrobial resistance, and medical comorbidities (File, 2013). For uncomplicated pneumonia in patients who do not need hospitalization, no comorbidities, and no antibiotic use in last 3 months, and do not live in a high prevalence of macrolide-resistant strains, it is recommended to use any one of the following regimens:Azithromycin 500 mg day one with 4 days 250 mg a day or 500 mg daily for three days.Clarithromycin 500 mg BID for five days or until afebrile for 48-72 hours.Clarithromycin XL Two 500 mg tablets (1000mg per dose) once daily for five days or until afebrile for 48-72 hours.Doxycycline 100 mg BID for 7-10 days.Many studies have been used to test the efficacy of empirical antibiotic use for CAP. The quality of the studies is influenced by several factors and lead to limitations in determining the certainty of their results. Reports may compare new agents to antibiotics not considered a standard treatment of CAP. These antibiotics include penicillin, ampicillin, and erythromycin. Studies use a small number of patients and may not have sufficient power to detect differences between treatment groups. Many studies are open-labeled trials. The definition of CAP is not uniform. Some studies do not require CXR to confirm infiltrates. Some studies involve children and adults and lack consistent study design (File 2013).The methodology of one study involved several large randomized treatment trials of CAP comparing fluoroquinolone therapy to treatment with beta-lactams with or without a macrolide. In each study, clinical responses were superior in patients treated with fluoroquinolones. In a meta-analysis involving 23 randomized trials, respiratory fluoroquinolones were more likely to result in treatment success than the combination of beta-lactam plus a macrolide for CAP treatment. However, limitations were seen when fluoroquinolones were more effective only when in open-labeled trials, not randomized controlled trials (File, 2013).Very Good!!!99% Very Good!References:Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, d. J. (Eds.). (2011).Primary care the art and science of advanced practice nursing (3rd ed.).Philadelphia: F.A. Davis.File, T. (2013). Antibiotic studies for the treatment of community-acquired pneumonia in Adults. Comparison of Specific Agents. Retrieved from , G. & Hensley, R. (2011). Clinical Guidelines in Primary Care: A Reference and Review Book. Lafayette, LA: Advanced Practice Education Associates, Inc. ................
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