Case Study For Pneumonia Prescription Assignment Paper
Case Study For Pneumonia Prescription Assignment Paper
SUBJECTIVE DATA:
Chief Complaint (CC): Fever and Cough
History of Present Illness (HPI): Mr. Jones is a 61-year-old male who presents with a chief complaint of fever and cough. He reports that the symptoms began suddenly two days ago and have worsened slightly since onset. He has a productive cough with mucopurulent sputum and pleuritic chest pain that is worsened with coughing. He has had a fever of up to 100.8F, chills, myalgia, and shortness of breath. He has tried Tylenol OTC for fever relief. His review of systems is otherwise negative Case Study For Pneumonia Prescription Assignment Paper.
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Medications
Lisinopril for hypertension
Tylenol OTC for pain relief
Allergies
No known food or drug allergies were reported.
Past Medical History
He has a history of hypertension
Past Surgical History
No history of any previous surgeries or procedures was reported.
Personal/Social History
Mr. Jones is a 61-year-old African American male who works in public transportation as a supervisor. He has a 20-year history of smoking but denies alcohol use. He is married and has two adult children, both of whom live in the same city. He is an active member of his church and enjoys playing basketball in his free time. He does not have any pets. His primary support system is his family and friends. Case Study For Pneumonia Prescription Assignment Paper
Immunization History
He is current on all vaccines, including two doses of the COVID-19 vaccine and the annual influenza vaccine.
Review of Systems
General Appearance: Mr. Jones is an elderly male in no acute distress. He is alert and oriented, with normal speech and movement. His skin appears to be slightly flushed and mildly diaphoretic. He is sitting upright in the exam chair with a normal posture. The patient is wearing a long sleeve shirt, jeans, and shoes. His eyes appear slightly sunken, and his respirations are shallow with mild effort.
HEENT
He reports no history of headaches, dizziness, visual disturbances, ear pain or discharge, nasal congestion, or sore throat. He denies any recent changes in his hearing or vision. He also denies any recent changes in his olfactory or gustatory senses.
Neck: Mr. Jones denies stiffness, pain, numbness, or tingling in the neck. He denies any swelling or lumps in the neck, as well as any difficulty swallowing or difficulty turning his head. He denies any history of neck injury and reports no change in voice. He also denies any history of thyroid problems.
Respiratory: He reports a cough that is productive with mucopurulent sputum, worsening since onset. He has pleuritic chest pain aggravated by coughing. He reports a fever that peaks after dinner, up to 100.8. He also reports chills. Myalgia is present with shortness of breath. No wheezing, nocturnal dyspnea, or chest tightness.
Cardiovascular: Reports pleuritic chest pain aggravated with coughing and shortness of breath.
Gastrointestinal: Reports no changes in his appetite or stool or urine habits. He denies nausea, vomiting, abdominal pain, heartburn, or bloating. He also denies any history of GERD, hepatitis, or other gastrointestinal issues. He does not take any medications for gastrointestinal issues and is not currently taking any antacids. He has not had any recent contact with any food-borne illnesses. Case Study For Pneumonia Prescription Assignment Paper
Genitourinary: Reports no genitourinary symptoms, including dysuria, urgency, frequency, or hematuria. He also reports no changes in his urinary habits, such as an increase or decrease in frequency or volume. He also denies any flank or abdominal pain and does not report any changes in his bowel habits. He denies any genital lesions, itching, burning, or discharge. He also reports no history of sexually transmitted infections.
Musculoskeletal: Mr. Jones reports myalgia but denies joint swelling, instability, deformity, or trauma. He also denies any numbness, tingling, or weakness. He denies any recent increase in activity or any history of gout or arthritis. He also denies any recent falls or fractures—no history of musculoskeletal issues or prior treatments.
Neurological: He denies any episodes of dizziness, headaches, memory loss, gait disturbance, falls, or seizures.
Endocrine: No cold/heat intolerance, no polyuria or polydipsia.
Psychiatric: No history of depression or any mental health disorder.
Skin, hair/nails: No skin rashes or lesions. Hair is well distributed with no hair loss. The nails are intact with no clubbing. Case Study For Pneumonia Prescription Assignment Paper
OBJECTIVE DATA
Physical Exam
Vital Signs: BP: 128/84, HR: 94b/min, Temp. 100.2F; Respiratory Rate 16 breaths per minute, Oxygen saturation: 96% on room air.
General: Mr. Jones is alert and oriented with normal speech and movement. His skin appears to be slightly flushed and mildly diaphoretic. His eyes appear slightly sunken, and his respirations are shallow with mild effort.
HEENT: On physical examination, Mr. Jones had a normal pupil responding appropriately to light reflex, no discharge on the conjunctiva, and white sclera on both eyes. No ear discharges.
Neck: No bruits on carotids, no thyromegaly.
Chest/Lungs: His lungs were clear on the upper lobe, with diminished breath sounds on the lower lobes. Dullness with percussion was appreciated on the left lower aspect of the posterior chest. There were no other abnormal physical findings.
Heart/Peripheral Vascular: No murmurs, rub, or gallop. Capillary refill less than 2 minutes.
Musculoskeletal: Symmetric muscle development. Myalgia present. Muscle strength 5/5 in all groups.
Neurological: All cranial nerves intact.
Skin/Lymph nodes: No edema, clubbing, or cyanosis.
Lab tests
COVID-19 test- Negative
Influenza Test- Negative
Blood tests, including complete blood count (CBC).
Chest X-Ray
What do you appreciate in the radiographic image (yellow arrows)? How do the findings on the image support the diagnosis?
The patient’s radiographic image shows an opacity (opaque white area) in the left lower lobe of the lung, indicating an area of consolidation from pneumonia. They also show patchy infiltrates in the upper and middle lobes and pleural effusion, an accumulation of fluid between the layers of the pleura. According to Garg et al. (2019), chest radiography can establish the presence of pneumonia, determine its extent and location, and assess the response to treatment. The radiographic image findings in this case study support the diagnosis of bacterial pneumonia by showing areas of consolidation, or “white-out” areas, indicating the presence of fluid in the alveoli due to infection. This is consistent with the patient’s report of fever and cough and the physical exam finding of dullness with percussion in the left lower aspect of the posterior chest Case Study For Pneumonia Prescription Assignment Paper.
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Write your management prescription:
What five key teaching points would you cover with this patient regarding managing his diagnosis?
I would advise Mr. Jones on the following areas:
Medication Adherence
I would advise him to take his medications as prescribed and avoid skipping doses. This will ensure that he takes the prescribed antibiotics for the full course of treatment to prevent antibiotic resistance development and reduce the risk of relapse due to inadequate treatment (Lui et al., 2020). Adherence also helps eliminate the infection, reducing the risk of complications and the need for additional treatments.
Healthy Lifestyle
A healthy lifestyle is important in managing bacterial pneumonia because it can help reduce the risk of complications and improve Mr. Jones’s overall health. Healthy lifestyle habits such as eating a balanced diet, getting regular exercise, avoiding smoking and alcohol, and managing stress can help boost the immune system and aid in recovery. In addition, it will ensure that he gets enough rest, which is essential for the body to fight off infection. This will reduce the risk of a recurrence of bacterial pneumonia and other respiratory illnesses.
Temperature monitoring
I would advise him to monitor his temperature continuously and seek additional care if the temperature rises above 100.8F. Adequate temperature monitoring will help identify any changes that may indicate the progression or regression of the condition. Sattar & Sharma (2019) note that a temperature rise may indicate a worsening of pneumonia, while a decrease in temperature may indicate that the patient is responding to treatment. Temperature monitoring can help determine the most effective course of treatment and alert the healthcare team to any potential complications. It can also help to monitor the patient’s recovery and check for any recurrence of the infection Case Study For Pneumonia Prescription Assignment Paper.
Proper Hygiene
Good hygiene practices can help prevent the spread of infection and reduce the risk of complications. I would educate Mr. Jones on proper handwashing to prevent the spread of bacteria to other people. I would also advise him on good respiratory hygiene, including covering the nose and mouth when coughing or sneezing to prevent the spread of the infection.
Differential Diagnoses
Viral pneumonia: This often presents symptoms similar to bacterial pneumonia, including fever, cough, shortness of breath, and pleuritic chest pain (Sattar & Sharma, 2019). However, viral pneumonia does not cause productive sputum.
Tuberculosis: This can present with similar symptoms to bacterial pneumonia, including fever, cough, and pleuritic chest pain. However, it is usually associated with night sweats and weight loss.
Asthma: Can also cause cough, wheezing, and shortness of breath, but it is usually not associated with fever or pleuritic chest pain.
Pulmonary Embolism: This condition can present with sudden onset of dyspnea, chest pain, and cough, but it is usually not associated with fever or productive sputum.
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References
Garg, M., Prabhakar, N., Gulati, A., Agarwal, R., & Dhooria, S. (2019). Spectrum of imaging findings in pulmonary infections. Part 1: Bacterial and viral. Polish Journal of Radiology, 84, e205–e213. https://doi.org/10.5114/pjr.2019.85812
Lui, G., To, H. K. W., Lee, N., Chan, R. W. Y., Li, T., Wong, R. Y. K., Hui, D. S. C., & Ip, M. (2020). Adherence to Treatment Guideline Improves Patient Outcomes in a Prospective Cohort of Adults Hospitalized for Community-Acquired Pneumonia. Open Forum Infectious Diseases, 7(5). https://doi.org/10.1093/ofid/ofaa146
Sattar, A., & Sharma, S. (2019). Bacterial Pneumonia. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513321/ Case Study For Pneumonia Prescription Assignment Paper