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Case Study 2 

B.G. is a 70 y.o. African American female patient that presents to the clinic today with a productive cough with green sputum and with wheezing for the past 7 days. The claimant has been taking over the counter “cold” medicine, as she believed that she had a cold, but her symptoms have not improved, but in fact, have worsened. Today, she reports an increase in shortness of breath and orthopnea.

Physical examination findings:

 

General: Patient appears in mild distress from persistent cough with some chest congestion. Appears fatigued. Overall healthy, except for her respiratory symptoms over the last week.
Lungs: Chest expansion symmetrical, respirations appeared unlabored and even with mild tachypnea with expiratory wheezing. Continuous productive cough with greenish-yellow sputum. Resonance percussed over upper chest; area of dullness percussed over left lower lobe. Increased tactile fremitus palpated in right lower lobe. BS are clear to auscultation bilaterally in upper lobes.
Xray: Lobar consolidation in the left lower lobe and bilateral infiltrates
Past Medical History: Hypertension, Hyperlipidemia, Vitamin D deficiency
Social History: No alcohol use, 1 PPD smoker X 30 years
VS: BP: 112/77, HR: 98, RR: 24, T: 102.1, SpO2: 94%, Ht: 5’3″, Wt: 160 lbs
Allergies: Penicillin

 

Medication List:

Tylenol Cold and Flu 500mg Q12 hours prn
Lisinopril 5mg PO Q day
Vitamin D 50,000 international units Once weekly

 

1.       Analyze the common pathogens that can cause uncomplicated community-acquired pneumonia.

2.       Discuss the first-line antimicrobial drugs for community-acquired pneumonia that would be best for this patient specifically (be mindful that this patient has a penicillin allergy).

3.       What are the indications for the use of antimicrobial therapy for community acquired pneumonia and discuss any necessary monitoring?

4.       Discuss the patient education that you would provide to this patient regarding antibiotic use.

SCIENCE
HEALTH SCIENCE
NURSING
NURS N521

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