Comprehensive Case Study

Natalie Noday

Walsh University

Angie Gager, MSN, FNP-BC

August 5, 2021
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Background

This case study represents a 78 year old male with a past medical history significant for

hypertension, hyperlipidemia, COPD, and CAD, whom presents to the office today with a chief

complaint of cold- like symptoms, and a cough that has been present for one week. He also

reports coughing up bloody sputum two days ago. The treatment strategy the patient tried was an

OTC cough medication, that had little effect. He also reports a brief period of chest pain upon

exertion, lasting a duration of 30 seconds. The patient does mention having similar pain in the

past. He states having no experiences with nausea, vomiting, dizziness, or headaches at this time.

The patient denies alcohol consumption or illicit drug use, but is a previous ex-smoker of fifty

years. He states he quit five years ago, but when he did smoke, he smoked a pack a day. He

reports no history of recent travel. However, he does report visiting his wife in a nursing home

facility two to three times a week. The patient has undergone a coronary artery bypass grafting

surgery two times (five years ago), and also has a surgical history of an appendectomy thirty

years ago. The patient’s current medication list includes: Lisinopril 10mg PO once daily,

Metoprolol 25mg PO BID, Aspirin 325mg PO once daily, Simvastatin 80 mg PO once daily,

Spiriva 18mcg once daily, and an Albuterol inhaler PRN.

Upon assessment, the patient’s vital signs and findings of the physical exam are

concerning for possible infection and potential sepsis. Furthermore, his vital signs include: BP of

90/54, HR 130 and irregular, febrile at 101.2 F, and respirations at 32 per minute. The patient

also appears to be pale, cool, and clammy. The patient is positive for expiratory wheezes

bilaterally. An irregular heart rate and rhythm, S1 and S2, with a III/VI systolic ejection murmur

was heard upon auscultation. He also has mildly elevated JVD and trace pedal edema. His pulses

are 2+ bilaterally throughout and no abdominal issues are noted.

Subjective Data

The chief complaint is established, however additional subjective data is important to

collect from this patient. This includes a thorough assessment from the mnemonic OLDCARTS,

to gather more information about his recent symptoms and presenting illness. For example,

specific details about the patient’s onset of symptoms, location, duration, character, aggravating

and relieving factors, radiation of symptoms, timing of symptoms, frequency, and severity (0-10

scale) are all crucial to collect. Accompanying cardiac and respiratory symptoms should also be

questioned, as well as the absence of these symptoms. More information should be collected in

regards to past medical history (such as history of murmur, cardiac issues, or respiratory issues),

pertinent family history, and further social history should be established. “An acronym that may

be used is HEADSS which stands for Home and Environment; Education, Employment, Eating;

Activities; Drugs; Sexuality; and Suicide/Depression” (Podder, et al., 2020). Current medications

should be updated along with the patient’s current allergies and immunizations to date.

Furthermore, given this patient’s age, the older adult should also be assessed from a neurological

stand point to gather orientation status. A more specific ROS for all body systems should be

collected, specifically: general, skin, HEENT, cardiac, respiratory, and the peripheral vascular

systems should be further discussed (Shadow Health, 2021).

Objective Data

Objective data from the patient’s encounter should include: vital signs, physical exam

findings, laboratory data, imaging results, important diagnostic criteria, and recognition and

review of the documentation from other clinicians. (Podder, et al., 2020). In regards to collecting

objective data in this patient’s clinical situation, it would be important to note the patient’s

overall general appearance given the information provided from the subjective data. For
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example, noting if the patient appears to be in any acute distress may change the plan of care for

this patient. Additionally, an oxygen saturation should be obtained with the initial vital signs.

Other objective data collection should be addressed through physical examination techniques of

inspection, palpitation, percussion, and auscultation of the focused exam area. (Shadow Health,

2021). For this patient, that includes information from the following review of systems: HEENT,

respiratory, cardiac, and the peripheral vascular systems.

To begin, I would assess the patient’s level of consciousness and his general appearance.

I would then inspect the symmetry of the patient’s chest expansion, and use of accessory

muscles, if any. I would also inspect the patient’s eyes, nasal cavity, mouth, throat, neck, and

upper/lower extremities (including hands, fingernails, toes, and toenails), observing for capillary

refill and observing for any tenting, edema, or abnormalities (rashes, discoloration, etc.) of the

skin. I would also palpate for tactile fremitus, and ensure palpation of the lymph nodes and

arteries. Percussing the chest wall would be important, noting bronchophony, egophony, or a

friction rub, that could be helpful in determining a diagnosis. Identifying the presence of bruits

and thrills, in addition to auscultation of the heart and lung sounds, are also pertinent due to the

patient’s heart rate, irregularity, and murmur that is present. (Shadow Health, 2021). Lab work

and diagnostic testing should be performed, such as a BMP, CBC, chest x-ray, and spirometry.

Based on the information provided in the case study, the three differential diagnoses I would

choose as the provider would include: community acquire pneumonia, bronchitis, and

tuberculosis (TB).

Pneumonia

The first diagnosis that is consistent with this patient’s findings is Pneumonia. Pneumonia

indicates an inflammatory process of the lung parenchyma caused by a microbial agent. This is
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mainly achieved when that agent reaches the alveoli by the oropharyngeal secretions. Once these

reach the alveolar space, pneumonia is created to then overcome the last defense mechanism of

the lung, which is the alveolar macrophage. (Ramirez, 2020). Pneumonia can be caused by a

variety of these micro-organisms, which may include: viruses, bacteria, and, less commonly,

fungi. (File, 2021). “The most common bacterial cause of pneumonia in the United States is a

type of bacteria called Streptococcus pneumoniae (also called pneumococcus)” (File, 2021).

Signs and symptoms of pneumonia include: cough (which may produce green, yellow, or

bloody mucous), fever, sweating, shaking, chills, shortness of breath, wheezing or crackles, rapid

and shallow breathing, sharp or stabbing chest pain that gets worse when coughing or taking a

deep breath, tachycardia, loss of appetite, low energy, fatigue, nausea, vomiting, or confusion

(especially in the older adult). (American Lung Association, 2021). There are specific factors

that can also increase the patient’s risk of developing pneumonia including: being over the age of

65, COPD, heart disease, history of smoking, and possible exposure of recent illness. (File,

2021). Furthermore, common physical findings upon assessment in a patient with pneumonia

includes: decreased or bronchial breath sounds, crackles, rales, or wheezes on auscultation of the

lung fields, and dullness during percussion. (Jain, et al., 2021) Based on the above information,

there is a high probability given this patient’s recent visitation to his wife’s nursing home, along

with his presenting signs and symptoms of: hypotension, fever, tachypnea, tachycardia,

hemoptysis, chest pain, and wheezing, that he may have developed a case of community-

acquired pneumonia.

Acute Bronchitis

Acute bronchitis is the second differential clinical diagnosis for this patient. Bronchitis is

characterized by a cough due to acute inflammation of the trachea and large airways, mainly
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caused by a viral infection, but bacterial infections can also be present. (Albert, 2010). It has

been found that, “the most commonly identified viruses are rhinovirus, enterovirus, influenza A

and B, parainfluenza, coronavirus, human metapneumovirus, and respiratory syncytial virus.

Bacteria are detected in 1% to 10% of cases of acute bronchitis. Atypical bacteria, such as

Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella pertussis, are rare causes

of acute bronchitis” (Albert, 2010). Irritants, such as smoke, polluted air, or dust can also cause

this inflammation of the trachea and large airways. Due to the inflammation of the bronchi from

the various different triggers mentioned, mucosal thickening occurs, leading to epithelial- cell

desquamation, and denudation of the basement membrane; leading to lower airway symptoms.

(Singh, 2021).

“Patients with acute bronchitis present with a productive cough, malaise, difficulty

breathing, and wheezing. Usually, their cough is the predominant complaint and the sputum is

clear or yellowish, although sometimes it can be purulent or blood-tinged” (Long & Kinkade,

2016). A prodrome of upper respiratory infection (URI) symptoms and cold- like symptoms such

as, runny nose, sore throat, fever, and malaise are also common. Due to the inflammation of the

airways, patients may report chest pain with deep breaths or movement. (Singh, 2021). On

physical examination, lung auscultation may be significant for wheezing. Tachycardia can be

present reflecting fever, as well as dehydration secondary to the viral illness. (Singh, 2021). In

this patient’s clinical situation, he presents with a productive (hemoptysis) cough, along with

fever, tachycardia, expiratory wheezing, and cold- like symptoms for one week. He also reports

having a 30 second episode of chest pain upon exertion.

“Laboratory testing is usually not indicated in the evaluation of acute bronchitis.

Leukocytosis is present in about 20% of patients; significant leukocytosis is more likely with a
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bacterial infection than with bronchitis. Although rapid testing is available for some respiratory

pathogens, it is usually not necessary in the typical ambulatory care patient. Testing for influenza

and pertussis may be considered when the suspicion is high and treatment would impact the

course of the illness” (Albert, 2010). Indications for chest radiography includes: dyspnea, bloody

sputum, or rust- colored sputum; pulse > 100 beats per minute; respiratory rate > 24 breaths per

minute; oral body temperature > 100.0 F; focal consolidation, egophony, or fremitus on chest

examination. (Albert, 2010).

Tuberculosis (TB)

The third differential diagnosis for this patient would be tuberculosis (TB), which is

caused by the airborne bacteria known as mycobacterium tuberculosis. “Transmission occurs

when a person inhales droplet nuclei containing M. tuberculosis, and the droplet nuclei traverse

the mouth or nasal passages, upper respiratory tract, and bronchi to reach the alveoli of the

lungs” (CDC, 2018, p. 56). Those who are at high risk for TB include: close contacts (those

sharing the same household or other enclosed environments with TB), residents and employees

of high- risk congregate settings (nursing homes, correctional institutes, homeless shelters),

elderly persons, and those who are immunocompromised. (CDC, 2021). The main symptoms of

TB include: chest pain, a persistent cough, and the hallmark symptom of hemoptysis. Other

symptoms patients may present with include: weakness or fatigue, anorexia, loss of appetite,

fever or chills, and night sweats. (CDC, 2021). Due to this patient’s age, immunocompromised

state r/t comorbidities, frequent visits to his wife’s nursing home, and symptoms he presents

with, this is an important diagnosis to rule out.

Plan

At this time, further medical care in the hospital should be warranted for this patient

based on his new onset of symptoms, clinical presentation, and physical assessment findings.

Once hospitalized, the patient can undergo lab work, diagnostic tests, and procedures in a timely

manner to rule out the differential diagnoses efficiently. The patient can also get the proper

medical care he needs in the meantime, being under direct observation of his healthcare team.

Early interventions and treatments can also be implemented to promote all lifesaving measures

and prevent rapid decline in the setting of sepsis or SIRS. The patient should potentially be

admitted to an intensive care unit where he can become hemodynamically stable under

continuous monitoring of his vital signs d/t his unstable HR, BP, and RR. IV fluids for

dehydration and low blood pressure would also be necessary. Broad spectrum antibiotics should

be started in the treatment of pneumonia, even if pneumonia is ruled out. Oxygen should be

applied or intubated depending on his oxygenation status.

Further diagnostic testing based on the potential diagnoses should include: BMP & CBC

(to evaluate WBC, leukocytosis), lactate, peripheral blood cultures x2, chest X-ray (pleural

effusions or infiltrates), pulse oximetry monitoring, sputum tests, CT scan of chest, arterial blood

gas (respiratory status, pH, CO2, oxygenation status), pleural fluid cultures, and bronchoscopy.

(American Lung Association, 2021). A C- reactive protein level may be drawn to determine

whether or not the patient could benefit from antibiotics. A procalcitonin level may also be

drawn to differentiate between a bronchitis diagnosis versus pneumonia. (Long & Kinkade,

2016). Since this patient appears to have an arrhythmia, a 12- lead ECG should be performed, as

well as an echocardiogram. Cardiac enzymes should also be drawn. The patient will also need to

be started on medication to help lower his HR, depending on the outcome of the 12- lead ECG.
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In regard to tuberculosis, according to the AAFP, a patient with suspected TB must have

a tuberculin skin test. If that results as positive, then the patient will get a chest radiograph. If

there is a positive finding (multinodular infiltrates above or behind the clavicle), sputum samples

for three acid- fast smears should be obtained. Mycobacterial cultures should also be obtained.

The patient should then be placed in a negative pressure room, on airborne precautions, until

diagnosis is definite. (Jerant & Bannon, 2012).

For successful follow up and patient education, the patient should be informed on his

medical condition from the moment of being in the outpatient office all the way until discharge

from the hospital. Explaining the potential risks of the differential diagnoses, and the benefits of

seeking higher medical care should also be discussed. The patient should be educated on any

new medications he may be going home with, as well as health care specialties he may be seeing

once he is home, if needed (cardiology, pulmonology). The patient should be informed of safe

hygiene practices, such as frequent handwashing and the importance of staying up to date on

vaccinations. Follow up within 5-7 days of hospital discharge is recommended. (AHRQ, 2021).

“Discharge education should be provided throughout the hospitalization and then understanding

confirmed on the day of discharge. There are tools available to help facilitate discharge

education such as “teach-back” which assesses the key learner’s understanding of the discharge

instructions. Another strategy is to incorporate a discharge checklist. Studies demonstrate the

value of discharge checklists to document required components for a safe discharge” (AHRQ,

2021).
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References

Agency for Healthcare Research and Quality (AHRQ). (2021). Discharge Planning and

Transitions of Care. https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-

care

Albert, R. (2010). Diagnosis and treatment of acute bronchitis. American Family Physician

(AAFP), 82(11), 1345-1350. https://www.aafp.org/afp/2010/1201/p1345.html

American Lung Association. (2021). Pneumonia.

https://www.lung.org/lung-health-

diseases/lung-disease-lookup/pneumonia

Centers for Disease Control and Prevention (CDC). (2018). Tuberculosis: guidelines for

diagnosis from the ATS, IDSA, and CDC. American Family Physician, 97(1), 56-58.

https://www.aafp.org/afp/2018/0101/p56.html

Centers for Disease Control and Prevention (CDC). 2021. Tuberculosis: Signs and Symptoms.

https://www.cdc.gov/tb/topic/basics/signsandsymptoms.htm

File, T. (2021). Patient education: pneumonia in adults (beyond the basics). UpToDate.

https://www.uptodate.com/contents/pneumonia-in-adults-beyond-the-basics

Jain, V., Vashisht, R., Yilmaz, G., & Bhardwaj, A. (2021). Pneumonia Pathology. Statpearls.

https://www.ncbi.nih.gov/booksNBK526116/

Jerant, A. & Bannon, M. (2012). Identification and management of Tuberculosis. American

Family Physician (AAFP), 61(9), 2667-2678.

https://www.aafp.org/afp/2000/0501/p2667.html

Long, N. & Kinkade, S. (2016). Acute bronchitis. American Family Physician (AAFP), 94(7),

560-565. https://www.aafp.org/afp/2016/1001/p560.html
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Podder, V., Lew V., Ghassemzadeh, S. (2020). SOAP notes. Statpearls.

https://www.ncbi.nlm.nih.gov/books/NBK482263/

Ramirez, J. (2020). Community acquired pneumonia. Infectious Disease: Antimicrobial Agents.

http://www.antimicrobe.org/index.asp

Shadow Health. (2021). An Elsevier Company. https://shadowhealth.com

Singh, A., Avula, A., & Zahn, E. (2021). Acute bronchitis. Statpearls.

https://www.ncbi.nlm.nih.gov/books/NBK448067/