Ms. Baker is a 68-year-old female who is brought to your office today by her daughter Rebecca. Ms. Baker 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. Baker 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. 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.
Ms. Baker 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.
Vital Signs: 99.2, 126/78, 90, 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 p.o. daily
• Losartan 50mg p.o. daily
• ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
• Caltrate 600mg+ D3 1 tablet p.o. daily
Diagnosis: Pneumonia
Directions: Answer the following 10 questions and upload your document to Canvas site by due date.
Question 1: What findings would you expect to be reported or seen on her chest x-ray results, given the diagnosis of pneumonia?
Question 2: Define further what type of pneumonia Ms. Baker 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. Baker’s subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.
Question 4: Ms. Baker 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. Baker has a known history of COPD. What is the gold standard for measuring airflow limitation?
Question 6: Ms. Baker 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.
a. DVT (Deep Vein Thrombosis)
b. Intermittent Claudication
c. Cellulitis
d. Electrolyte Imbalance
Question 7: Ms. Baker 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. Baker’s initial presentation.
Question 9: What patient education would you give Ms. Baker 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. Baker’s Pneumonia? Explain why or why not.
Full Answer Section
- Consolidation: A hazy area in the left lower lung field, indicating an accumulation of fluid and inflammatory cells.
- Air bronchograms: Silhouettes of air-filled bronchi within the consolidated area.
- Blurring of the lung margins: Loss of the sharp border between the lung and the surrounding tissues.
- Elevation of the diaphragm: The muscle separating the chest from the abdomen might be pushed down due to fluid accumulation in the lung base.
Question 2: HAP vs. CAP:
Ms. Baker's pneumonia is most likely Community-Acquired Pneumonia (CAP) rather than Hospital-Acquired Pneumonia (HAP). Here's the difference:
- Onset: CAP develops within the community, while HAP develops after admission to a healthcare facility.
- Pathogens: CAP is usually caused by bacteria like Streptococcus pneumoniae, Haemophilus influenzae, or Mycoplasma pneumoniae. HAP often involves more resistant organisms like Pseudomonas aeruginosa or methicillin-resistant Staphylococcus aureus (MRSA).
- Risk factors: CAP risk factors include smoking, COPD, chronic heart disease, and older age. HAP risk factors include mechanical ventilation, recent surgery, and indwelling catheters.
Question 3: Severity and Treatment Options:
3A) The Pneumonia Severity Index (PSI) is a tool used to determine the severity of CAP and guide treatment decisions. It considers factors like age, comorbidities, vital signs, and oxygen saturation.
3B) Applying PSI to Ms. Baker's case:
- Age: 68 points
- COPD: 20 points
- Tachycardia: 20 points
- Normal oxygen saturation: 0 points
Total PSI score: 108
Based on her score, Ms. Baker falls into the "Low-risk" category. This suggests outpatient treatment with oral antibiotics and close follow-up is appropriate.
Question 4: Treatment for Ms. Baker's Pneumonia:
Current guidelines recommend amoxicillin as first-line treatment for outpatients with low-risk CAP. Alternative choices include doxycycline, clarithromycin, or azithromycin.
For Ms. Baker, considering her age and COPD, amoxicillin would be a suitable option. However, additional factors like allergies and potential drug interactions should be considered.
Question 5: Gold Standard for Airflow Limitation:
The gold standard for measuring airflow limitation is spirometry. This test measures the amount and speed of air you can breathe in and out. It helps diagnose and assess the severity of COPD and other respiratory conditions.
Question 6: Potential Diagnosis for Leg Pain:
The most likely diagnosis for Ms. Baker's leg pain is intermittent claudication, based on her symptoms of:
- Bilateral leg pain
- Pain occurring with walking
- Need to rest for the pain to subside
Intermittent claudication is caused by narrowed arteries in the legs, which restrict blood flow during exercise. Other options like DVT and cellulitis are less likely due to the lack of other supporting symptoms.
Question 7: Test for Leg Pain Evaluation:
Doppler ultrasound is the best test to further evaluate Ms. Baker's leg pain. It can detect narrowed arteries and assess blood flow in the legs, confirming or ruling out intermittent claudication.
Question 8: Differentials for Ms. Baker's Presentation:
Three differentials for Ms. Baker's initial presentation include:
- Heart failure: Her COPD and tachycardia could be related to heart failure, which can cause fluid buildup in the lungs and legs.
- Exacerbation of COPD: Her cough and leg pain could be due to a worsening of her existing COPD, potentially triggered by an infection.
- Pulmonary embolism: Although less likely, a blood clot in the lungs (pulmonary embolism) could explain her cough, tachycardia, and leg pain.
**Question 9: Patient Education and **
- Pneumonia: Educate Ms. Baker and her daughter about the importance of completing the full course of antibiotics, managing symptoms like fever and cough, and recognizing signs of worsening like increased shortness of breath or chest pain.
Sample Answer
This case study presents Ms. Baker, a 68-year-old female with a history of COPD, hypertension, vitamin D deficiency, and hyperlipidemia. She presents with complaints of tachycardia, coughing, and intermittent leg pain. The initial diagnosis is pneumonia, likely affecting the left lower lobe.
Question 1: Chest X-ray Findings in Pneumonia:
Chest x-ray findings in pneumonia can vary depending on the severity and stage of the infection. In Ms. Baker's case, we might expect to see: