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 can 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 include 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 must 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. 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.
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: hives
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. put in bold or a different color 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. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia). What are the differences/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.
DVT (Deep Vein Thrombosis)
Intermittent Claudication
Cellulitis
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. Support your research answers with 5 APA citations.
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