NRNP 6540 Week 5 Case Assignment – 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

In this clinical scenario, we encounter Ms. Jones, a 67-year-old woman, who is accompanied by her daughter, Susan, for her office visit. Ms. Jones resides with her daughter and maintains her independence in performing activities of daily living (ADLs). Concerningly, her daughter reports a significant increase in her mother’s heart rate, accompanied by persistent coughing over the past two days.

Ms. Jones has a notable history of tobacco use, with a smoking history of 30 packs per year; however, she successfully quit smoking three years ago. Additionally, her medical history includes chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. Furthermore, she reports intermittent pain and cramping in her lower extremities when walking, occasionally necessitating breaks for pain relief. She also experiences left-sided back pain and discomfort during aspiration.

Ms. Jones acknowledges her recent and frequent bouts of coughing, accompanied by the production of thick, brown-tinged sputum. She attributes this to her COPD and an increased usage of her albuterol inhaler, which she finds helpful in loosening mucus. Although she describes a sense of fatigue and weakness, she still manages to fulfill her daily routine. Case Title: A 67-year-old With Tachycardia and Coughing

Vital Signs: Ms. Jones’ vital signs indicate a temperature of 99.2°F, blood pressure at 126/78 mm Hg, a heart rate of 96 beats per minute, and a respiratory rate of 22 breaths per minute.

Laboratory Results: A Complete Metabolic Panel and CBC were performed, and the results fell within the normal range.

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

Patient Information and Medical History:

Allergies: Penicillin

List of Current Medications:

– Atorvastatin 40mg orally once daily
– Multivitamin 1 tablet taken daily
– Losartan 50mg orally once daily
– ProAir HFA 90mcg: 2 puffs every 4-6 hours as needed
– Caltrate 600mg+ D3: 1 tablet daily

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Example

Diagnosis: Pneumonia

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

In this clinical scenario, we encounter Ms. Jones, a 67-year-old woman, who is accompanied by her daughter, Susan, for her office visit. Ms. Jones resides with her daughter and maintains her independence in performing activities of daily living (ADLs). Concerningly, her daughter reports a significant increase in her mother’s heart rate, accompanied by persistent coughing over the past two days.

Ms. Jones has a notable history of tobacco use, with a smoking history of 30 packs per year; however, she successfully quit smoking three years ago. Additionally, her medical history includes chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. Furthermore, she reports intermittent pain and cramping in her lower extremities when walking, occasionally necessitating breaks for pain relief. She also experiences left-sided back pain and discomfort during aspiration.

Ms. Jones acknowledges her recent and frequent bouts of coughing, accompanied by the production of thick, brown-tinged sputum. She attributes this to her COPD and an increased usage of her albuterol inhaler, which she finds helpful in loosening mucus. Although she describes a sense of fatigue and weakness, she still manages to fulfill her daily routine.

Vital Signs:

Ms. Jones’ vital signs indicate a temperature of 99.2°F, blood pressure at 126/78 mm Hg, a heart rate of 96 beats per minute, and a respiratory rate of 22 breaths per minute.

Laboratory Results:

A Complete Metabolic Panel and CBC were performed, and the results fell within the normal range.

Now, let’s proceed to answer the provided questions:

Question 1: Expected Findings on Chest X-Ray Results

Chest X-ray results may reveal the presence of white infiltrates in the lungs, which can be indicative of infection and help confirm the diagnosis of pneumonia.

Question 2: Type of Pneumonia Ms. Jones has

Ms. Jones is diagnosed with community-acquired pneumonia (CAP). CAP is contracted outside of a clinical environment, and in this case, Ms. Jones did not acquire the illness from a healthcare facility.

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

The CURB-65 calculator is a valuable tool to assess the severity of community-acquired pneumonia. It considers factors like confusion, uremia, respiratory rate, blood pressure, and age over 65 (CURB-65). Based on Ms. Jones’ clinical presentation, she scores 1 on the CURB-65 scale, suggesting outpatient treatment.

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

Ms. Jones’ CURB-65 score is calculated as follows: she is not confused, her BUN level is 17 mg/dl, her respiratory rate is 22, her systolic pressure is 126, and she is 67 years old. With a score of 1, outpatient treatment is recommended.

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

Given her penicillin allergy and the nature of her condition, I recommend a treatment regimen consisting of Levofloxacin 750 mg orally once daily for five days. Additionally, considering her intermittent leg pain, prescribing 100 mg of cilostazol orally twice a day would be appropriate.

Question 5: Gold Standard for Measuring Airflow Limitation

The gold standard for measuring airflow limitation in COPD is spirometry. It is crucial to confirm COPD and determine the appropriate treatment plan.

Question 6: Best Choice for a Potential Diagnosis

Intermittent claudication is a potential diagnosis based on the intermittent leg pain and cramping experienced by Ms. Jones. This condition often results from peripheral artery disease, causing pain during exertion that subsides with rest.

Question 7: Test to Evaluate Intermittent Pain in Bilateral Legs

To further evaluate Ms. Jones’ intermittent leg pain, an Ankle-Brachial Index (ABI) test could be ordered. This test compares blood pressure measurements in the arm and ankle and can detect arterial blockages or obstructions.

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

Three differentials for Ms. Jones’ initial presentation could include COPD exacerbation, Cardiogenic Pulmonary Edema, and Influenza.

Question 9: Patient Education and Follow-Up Instructions

Patient education should include information on the increased risk of pneumonia in unvaccinated individuals, particularly those with underlying conditions like hypertension and COPD. Ms. Jones should be advised to stay hydrated, perform frequent coughing, and engage in deep breathing exercises.

A follow-up appointment within two to three weeks is recommended. Ms. Jones should be instructed to contact a healthcare provider if her cough worsens or if her leg pain persists.

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

Amoxicillin/clavulanate plus a macrolide could have been an option to treat Ms. Jones’ pneumonia, considering her penicillin allergy. This combination is effective in enhancing mucociliary clearance and reducing the inflammatory response, potentially leading to improved health outcomes.

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