Posted: December 29th, 2022

Case Title: A 67-year-old With Tachycardia and Coughing

NRNP 6540 Week 5 Case Assignment – Case Title: A 67-year-old With Tachycardia and Coughing

Ms. Jones is a 67-year-old female who is 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 2 days. Ms. Jones has a 30-pack per year history of smoking cigarettes but quit smoking 3 years ago. Other known history includes chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia Case Title: A 67-year-old With Tachycardia and Coughing. 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 to the left side of her back, and some pain with aspiration.

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Ms. Jones reports she has been coughing a lot lately, and notices 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 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. Case Title: A 67-year-old With Tachycardia and Coughing

Vital Signs: 99.2, 126/78, 96, RR 22

Labs: Complete Metabolic Panel and CBC done and were within normal limits

CMP Component	Value	CBC Component	Value
Glucose, Serum	86 mg/dL	White blood cell count	5.0 x 10E3/uL
BUN	17 mg/dL	RBC	4.71 x10E6/uL
Creatinine, Serum	0.63 mg/dL	Hemoglobin	10.9 g/dL
EGFR	120 mL/min	Hematocrit	36.4%
Sodium, Serum	141 mmol/L	Mean Corpuscular Volume	79 fL
Potassium, Serum	4.0 mmol/L	Mean Corpus HgB	28.9 pg
Chloride, Serum	100 mmol/L	Mean Corpus HgB Conc	32.5 g/dL
Carbon Dioxide	26 mmol/L	RBC Distribution Width	12.3%
Calcium	8.7 mg/dL	Platelet Count	178 x 10E3/uL
Protein, Total, Serum	6.0 g/dL
Albumin	4.8 g/dL
Globulin	2.4 g/dL
Bilirubin	1.0 mg/dL
AST	17 IU/L
ALT	15 IU/L

 

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

Directions: Answer the following 10 questions directly on this template.

Question 1: What findings would you expect to be reported or seen on her chest x-ray results, given the diagnosis of pneumonia? Case Title: A 67-year-old With Tachycardia and Coughing

Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?

Question 3:

• 3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?
• 3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.

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?

Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?

Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning. Case Title: A 67-year-old With Tachycardia and Coughing

1. DVT (Deep Vein Thrombosis)
2. Intermittent Claudication
3. Cellulitis
4. Electrolyte Imbalance

Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?

Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.

Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?

Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.

 

 

67-year-old with Tachycardia & Cough

Question 1: Expected Findings on Chest X-Ray Results,

The presence of white infiltrates in the lungs may be seen on an x-ray, which can be utilized to confirm the infection.

Question 2: Type of Pneumonia Ms. Jones has

Mr. Jones is suffering from community-acquired pneumonia. CAP is contracted outside of a clinical environment (Poovieng et al., 2022). As far as we know, Ms. Jones did not contract the illness from the hospital or care facility. As such, her type of pneumonia cannot be hospital-acquired pneumonia.

Question 3A: Assessment Tool Used to Determine the Severity of Pneumonia and Treatment Options

A CURB-65 calculator is an assessment tool that can be used to determine the severity of a person’s community-acquired pneumonia. This tool gives points for confusion and blood urea nitrogen, which is an older patient who is severely sick might be caused by a number of different things.

Question 3B: Application of the Assessment tool Based on Subjective and Objective Findings

CURB-65 stands for confusion, uremia, respiratory rate, BP, age 65 and over (Ilg et al., 2018). It is evident that Ms. Jones understands her symptoms and is not confused; her BUN level is 17 mg/dl; she has an RRR of 22; her systolic pressure is 126; she’s 67 years old. The CURB-65 score for Ms. Jones is 1, which suggests that she should receive outpatient treatment.

Question 4: Treatment Based On Diagnosis, Case Scenario, and Evidence-Based Guidelines

Levofloxacin 750 mg PO daily for five days would be my recommendation for Ms. Jones, given her history of penicillin allergy and the intensity of her condition. For intermittent claudication, I would also prescribe 100 mg of cilostazol PO twice a day. Case Title: A 67-year-old With Tachycardia and Coughing

Question 5: Gold Standard for Measuring Airflow Limitation

Spirometry is necessary for Ms. Jones due to her history of COPD. Spirometry is the standard method for confirming the presence of COPD and determining the best course of therapy (Global Initiative for Chronic Obstructive Lung Disease, 2020).

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Question 6: Best Choice for a Potential Diagnosis

Intermittent claudication is a possible diagnosis in this case. The most prevalent cause of intermittent claudication is a peripheral atherosclerotic artery, which causes leg pain while exerted and alleviates it when resting. Symptom progress has not been provided in the case study. If the symptoms progress quickly, they are probably not caused by atherosclerosis but rather by a nonatherosclerotic claudication etiology like atherothrombosis and arteritis (Patel, S & Surowiec, 2021).

Question 7: Test to Evaluate Intermittent Pain in Bilateral Legs

The ideal test would be the Ankle-brachial index (ABI). The blood pressure in the arm and ankle are compared during this sort of testing. An arterial blockage or obstruction may be present if there is any discrepancy between the two measurements (Herraiz-Adillo et al., 2020).

Question 8: Three Differentials for Ms. Jones’ Initial Presentation

COPD exacerbation, Cardiogenic Pulmonary Edema, and Influenza

Question 9: Patient Education and Follow-Up Instructions

The patient and her daughter should be taught that unvaccinated individuals, particularly those with concomitant conditions like hypertension and COPD, are at an increased risk of developing life-threatening pneumonia (Seo et al., 2020). The patient should be instructed to drink lots of fluids, cough many times a day, and do deep breathing exercises.

There should be a follow-up appointment within the next two to three weeks. If the cough becomes more severe, the patient should contact a healthcare practitioner. Similarly, if the patient’s legs continue to hurt, she should see the doctor.

Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia?

The patient may be prescribed amoxicillin/clavulanate together with a macrolide regardless of her comorbid conditions. Because of its ability to increase mucociliary clearance and minimize the inflammatory reaction, this combination has been recommended to enhance health outcomes (Ito et al., 2019). Case Title: A 67-year-old With Tachycardia and Coughing

 

 

References

Global Initiative for Chronic Obstructive Lung Disease. (2020). GOLD spirometry guide. https://goldcopd.org/gold-spirometry-guide/

Herraiz-Adillo, Á., Cavero-Redondo, I., Álvarez-Bueno, C., Pozuelo-Carrascosa, D. P., & Solera-Martínez, M. (2020). The accuracy of toe brachial index and ankle brachial index in the diagnosis of lower limb peripheral arterial disease: A systematic review and meta-analysis. Atherosclerosis, 315, 81-92. https://doi.org/10.1016/j.atherosclerosis.2020.09.026

Ilg, A., Moskowitz, A., Konanki, V., Patel, P., Chase, M., Grossestreuer, A., & Donnino, M. (2018). 1054: Performance of curb-65 in predicting critical care interventions in patients with pneumonia. Critical Care Medicine, 46(1), 511-511. https://doi.org/10.1097/01.ccm.0000529060.29903.34

Ito, A., Ishida, T., Tachibana, H., Tokumasu, H., Yamazaki, A., & Washio, Y. (2019). Azithromycin combination therapy for community-acquired pneumonia: propensity score analysis. Scientific Report, 9(18406). https://doi.org/10.1038/s41598-019-54922-4

Patel, S. K., & Surowiec, S. M. (2021). Intermittent claudication. In StatPearls [Internet]. StatPearls Publishing. Case Title: A 67-year-old With Tachycardia and Coughing

Poovieng, J., Sakboonyarat, B., & Nasomsong, W. (2022). Bacterial etiology and mortality rate in community-acquired pneumonia, healthcare-associated pneumonia and hospital-acquired pneumonia in Thai university hospital. Scientific Reports, 12(1). https://doi.org/10.1038/s41598-022-12904-z

Seo, W. J., Kang, J., Kang, H. K., Park, S. H., Koo, H., Park, H. K., Lee, S., Song, J. E., Kwak, Y. G., & Kang, J. (2022). Impact of prior vaccination on clinical outcomes of patients with COVID-19. Emerging Microbes & Infections, 11(1), 1316-1324. https://doi.org/10.1080/22221751.2022.2069516  Case Title: A 67-year-old With Tachycardia and Coughing