Mr. L.B is a 58 year old Caucasian male who comes in the clinic with a complaint of intermittent cough for the past four days.

Mr. L.B is a 58 year old Caucasian male who comes in the clinic with a complaint of intermittent cough for the past four days. It started out as a dry cough but over the past two days, he has started coughing up thick pale yellow phlegm. He thinks he has had a fever but he has not actually taken his temperature. He is a smoker but has not been smoking very much the past few days as that seems to make the cough worse. He has also felt very tired. He has taken Tylenol off and on and it does help slightly. About a week and a half ago, he played poker with some friends and one of them was sick. His wife accompanies him and when you ask them both, they deny that he has had any confusion.

Please write the following:

Therapeutic intervention:

Pharmacological intervention

No pharmacological intervention

Education

Health Promotion

Disposition/disease prevention

Follow up

Reflection/conclusion

1. What Physical Exam would you obtain?

· Does he has any history of upper respiratory tract infections such as colds and cough? When did it start and for how long? Do you have productive or non-productive cough? What is the color of the mucus and its consistency? What are the other symptoms experienced, do you have fever, joint pain, shortness of breath, chest pain, headache, diarrhea and vomiting? Any measures or treatment done/receiving and medicines taken? Any weight change?

· Have you been in contact with any other people with any infections such as respiratory tract infections? When was the last contact?

· Are you smoking? Are you using cigarettes, tobacco or vape? How many packs or sticks in a day? How long have you been smoking?

· Are you using alcohol or illegal drugs? What alcohol or drugs do you consume? How many times a week or in a month? How long you’ve been using them?

· Did you recently travel outside the country? When and where?

· Did you have any recent injury in the rib area?

· Ask for the past medical history and any pre-existing respiratory disease such as COPD and asthma as well as family history of respiratory diseases such as cystic fibrosis

· Inquire as well for the past surgical history

· Inquire about his occupation and hobbies. Does he have pets like birds and cats? Is he expose in chemicals or other substances such as in mining?

· Inquire about immunization history against respiratory diseases such as Influenza, Tuberculosis or Pneumococcus

· Does he has any history of upper respiratory tract infections such as colds and cough? When did it start and for how long? Do you have productive or non-productive cough? What is the color of the mucus and its consistency? What are the other symptoms experienced, do you have fever, joint pain, shortness of breath, chest pain, headache, diarrhea and vomiting? Any measures or treatment done/receiving and medicines taken? Any weight change?

· Have you been in contact with any other people with any infections such as respiratory tract infections? When was the last contact?

2. What Physical Exam would you obtain?

· I would use a stethoscope to listen to his breathing for sounds that indicate a problem in his lungs

· Systemic: check the vital signs especially the temperature, if the patient is febrile. Check also the weight to compare if he had any weight loss

· Neurological: assess the patient mental acuity by assessing orientation. Check for any visual changes and disturbances in sensory or motor (like any tingling or numbness and weaknesses on the extremities)

· Cardiovascular: check the vital signs which include the blood pressure and heart rate. Check for any edema

· Gastrointestinal: assess for any tenderness in the abdomen. Inquire for any nausea and vomiting as well as any difficulty in eating and appetite

· Genitourinary: check for any tenderness. Ask about the urinary output whether patient has polyuria or oliguria

· Respiratory: Assess for the breathing pattern, is it fast or shallow, or is there any difficulty? Check vital signs which include oxygen saturation and respiratory rate. Auscultate the lungs for breath sounds

3. What labs/diagnostics would you order?

· I would order an chest X-ray or CT scan to look for visible signs of TB in your lungs. They may also check the sputum (coughed-up mucus) for bacteria.

· The two important labs and diagnostics that I would order will be Complete Blood Count and Chest x-ray

· The CBC is to check for any infection and the possible cause whether it is viral or bacterial. The chest x-ray is needed to guide in diagnosing the patient’s case like if it is infection, you can exclude whether it’s pneumonia or tuberculosis

4. List your top four differential diagnoses. List your rationale for your top diagnosis.

· Common Cold or Influenza – patient has symptoms of common colds such as cough and fever

· Pneumonia – patient had an exposure from someone who is “sick” before exhibiting the symptoms

· Acute bronchitis – due to the cough

· Other upper respiratory tract infections such as pharyngitis and tonsillitis – due to the symptoms of cough and fever

The main concern of the patient is cough, and with that we highly considered diagnosis pertaining to the Respiratory tract.

5. What is a CURB Score? (1 point)

A score to estimate the mortality of CAP to help determine inpatient vs. outpatient treatment.

CURB stands for Confusion, Urea, Respiratory rate, Blood pressure.

It is a scoring system that is used to check the severity of the Pneumonia and help determine whether it needs an inpatient or outpatient treatment

6. When his labs come back, his CMP shows that his BUN is 21. Based on that information and on his presentation, what is his CURB score and how did you arrive at that score?

CURB uses 4 criterias namely Confusion, Urea, Respiratory rate and Blood pressure.

Confusion – patient and wife deny of confusion so the score is 0

Urea – BUN is above 19mg/dl (patient’s level 21) so the score is 1

Respiratory rate – is below 30. Patient’s RR is 26. The score is 0

Blood pressure – Systolic bp is not less than 90mmHg and the diastolic bp is not less than 60 (patient’s BP is 150/94mmHg) so the score here is 0

Total score of: 1. Patient’s CURB score is 1

7. Based on his CURB score, should he be treated on an outpatient or inpatient basis? The patient will be handled as outpatient based on its score of 1 on which as per CURB score the disposition will be outpatient.

8. His chest x-ray does indeed show infiltrates. What is your treatment plan for him?

Infiltrates in chest x-ray means the patient has pneumonia. Treatment plan includes taking of medications. Depending in the cause, the patient will be prescribed antibiotics if it is bacterial and antiviral if it is viral. He will also take antipyretic drugs to control his fever such as paracetamol or acetaminophen or NSAIDS like aspirin.

Patient will be advised to drink plenty of water and take warm beverages, use a humidifier or take a steamy bath as it helps open the airways and eases the breathing.

Advised the patient to get lots of rest while recovering and refrain from smoking.

As per the antibiotics, since the patient is allergic to Penicillin, he will be prescribed medications that are unrelated and safe for penicillin allergic patients such as Clarithromycine (macrolides), Ciprofloxacine (quinolones), Vancomycin (glycopeptides), Gentamicin (aminoglycosides) and Doxycycline (tetracyclines).

9.Name 3 health promotion topics that you should discuss with him.

· Smoking cessation – smoking can cause several health problems and not only limited to respiratory problems; smoking can also exacerbates or increases the recurrence of the patient’s pneumonia

· Control of blood sugar – patient is not foliwing up regarding his control of diabetes. It is important to keep his blood sugar under control because poor management of blood sugar may predisposes the patient to different illnesses and that includes higher risk of infection

· Consider taking immunizations – patient should consider taking immunizations if he didn’t receive any yet. This will help him to protect his body from contracting certain diseases or at least lessen the risk of its complications

· Other health promotion includes a healthy lifestyle such as exercising and proper diet. Overall health is important to make the body fight for infections and diseases.

10. What is your follow up plan?

First, advice the patient to report any worsening of condition. Instruct the patient to finish the course of treatment especially the antibiotics/antiviral medications.

I will advice the patient for a follow up visit after finishing the antibiotics or after one week from the start of the course of antibiotics, whichever comes first. Focused respiratory assessment will be done. Chest x-ray will be ordered to confirm if the pneumonia was resolved.

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