Nursing 704C - Pathophysiology of Altered Health States II
Case Study #2
You may complete the case study below and the quiz on Carmen by yourself or with your peers.
Prior to reading this case study, please review the following:
Differential diagnosis
Inpatient vs outpatient treatment
PSI scale
CURB 65 scale
History of present illness
Review of systems
Click Next to start the Case Study.
Pneumonia is an infection of the lower respiratory tract that can be caused by bacteria, fungi, viruses, protozoa, or parasites. Community-acquired pneumonia (CAP) occurs in patients who have gotten the infection in the community compared to nosocomial pneumonia which is acquired in a healthcare setting such as a hospital or a nursing facility. Pneumonia has considerable morbidity and mortality, especially in older adults (McCance & Heuther, 2010).
This case study will discuss community-acquired pneumonia. In CAP, it is important to understand the most common causative pathogens. CAP is usually viral or bacterial. Cap can be caused by typical or atypical pathogens. Pneumonia is often characterized by classic symptoms (SOB, wheezing, fatigue, fever); however, symptom presentation may vary slightly depending on the offending microorganism (Miskovich-Riddle & Keresztes, 2006). Common typical bacteria and atypical organisms that cause pneumonia are listed below.
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"Typical" bacteria |
"Atypical" pathogens |
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S. pneumonia (~40-70% of CAP), S. aureus (~10 of CAP), H. influenzae, M. catarrhalis, group A streptococci |
M. pneumonia (~10-25% of CAP), C. pneumonia (~5-15% of CAP), Legionella pneumophila (~5-10% of CAP), viruses |
(Riddle & Keresztes, 2006)
The clinician is unable to distinguish amongst causative pathogens of pneumonia based on an individual's symptoms and physical exam. Laboratory studies must be collected to determine the offending microorganism (Marrie, 2013). However, CAP is usually treated empirically for the most common causative organisms, so cultures are not always indicated.
http://internalmedicine.osu.edu/pulmonary/cap/10665.cfm
The lungs are constantly exposed to pathogens through aspiration; however, the lower airways usually remain sterile related to innate and acquired immunity of the pulmonary system (Marrie, 2013). Pneumonia can develop after aspiration of oropharyngeal secretions, inhalation of causative microorganisms, or when bacteria from an infection elsewhere in the body spreads to the lungs (ex. Bacteremia caused by IV drug use). If pathogens are able to move past the first line of defense in the upper airway (i.e. cough reflex, mucociliary clearance) to the lower respiratory tract, development of pneumonia depends of virulence of the microorganism and the host's defenses (McCance & Heuther, 2010).
Factors that can increase the host's risk for infection include:
(Marrie, 2013; McCance & Heuther, 2010)
CAP is most commonly caused by aspiration or inhalation of microorganisms through the nasopharynx or oropharynx. Microorganisms are usually trapped in the mucous-producing cells and cilia that line the upper airway. Factors that can impair the lungs' first line of defense include suppressed cough reflex, decreased ciliary action, decreased activity of phagocytic cells, and the accumulation of secretions. If the microorganism gets past the upper airways line of defense, the next line of defense is the airway epithelial cells which contain alveolar macrophages. Alveolar macrophages release cytokines and cause widespread inflammation in the lungs in an attempt to activate the immune response. The products of inflammation (inflammatory mediators, immune complexes) can damage the lung tissue and cause the terminal bronchioles to fill with infectious debris and exudates. Some microorganisms also release toxins which can cause further damage to the alveolar walls. Accumulation of exudates can leads to alveolar edema resulting in dyspnea and hypoxemia (McCance & Heuther, 2013, Miskovich-Riddle & Keresztes, 2006).
Typical bacteria will usually cause lobar pneumonia which is characterized by consolidation in a portion of the entirety of one lung (Miskovich-Riddle & Keresztes, 2006 ). In lobar pneumonia, biproducts of inflammation such as cytokines damage the fragile alveoli and cause edema. This edema becomes are good medium for further bacterial proliferation and colonization. The inflammatory response results in solidification of the lung tissue as it fills with exudate of blood, fibrin, bacteria, etc. causing a reddened appearance of the lungs. This is called red hepatization. Red hepatization eventually progresses to gray hepatization; the lung tissue turns gray from fibrin deposition and phagocytosis by neutrophils of the inflammatory biproducts and microorganisms. Resolution follows when neutrophils are replaced by macrophages, eventually eliminating the infection (McCance & Heuther, 2010).
Atypical pathogens generally cause bronchopneumonia or interstitial infiltrate characterized by patchy inflammation and edema of both lungs (Miskovich-Riddle & Keresztes, 2006).
Common signs and symptoms of CAP include:
(Marrie, 2013)
http://en.wikipedia.org/wiki/Pneumonia
To listen to adventitious breath sounds, please visit the youtube video below:
http://www.youtube.com/watch?v=5JA6D1Mguh
The "gold standard" for diagnosis of CAP is chest radiography. If pneumonia is suspected based on history of present illness, subjective symptoms, and physical exam, the clinician should obtain a standard chest x ray with PA and lateral views. Patients that may benefit from a chest xray include the following:
(Watkins & Lemonovich, 2011)
On plain films, typical bacteria may be suspected when lobar consolidation, cavitation, or pleural effusion is present. Diffuse infiltration (bilateral "white outs") are more often associated with an atypical pathogen.
Left: Lobar consolidation in the right lower lobe
Right: Bilateral infiltrates (aka: "white outs")
A normal chest xray; no pneumonia present
In the outpatient setting, sputum cultures are not indicated. If the clinician suspects a pathogen that would alter the patient's treatment regimen from the guidelines, laboratory testing can be performed. Clinical findings that may indicate specific laboratory evaluation can be found in table 3 of the article by Watkins & Lemonovich (2011). Empiric therapy after diagnosis via chest radiography is generally the standard.
Pneumonia is an illness with considerable morbidity and mortality. After diagnosis is confirmed, it is important to assess whether or not outpatient treatment is safe. Patients with acute illness may need hospitalization. Both the Pneumonia Severity Index and the CURB-65 scales can be used to assist the clinician in determining whether inpatient or outpatient treatment is appropriate.
The PSI classifies the patients risk from class I through V. Class I patients can be treated at home with oral antibiotics. Classes II and III should be treated with either brief hospitalization (~24 hrs) or treated at home with IV antibiotics. Classes IV and V should be hospitalized. The PSI algorithm is listed below:
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Step 1: Stratify to Risk Class I vs. Risk Classes II-V |
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Presence of: |
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Over 50 years of age |
Yes/No |
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Altered mental status |
Yes/No |
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Pulse ≥125/minute |
Yes/No |
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Respiratory rate >30/minute |
Yes/No |
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Systolic blood pressure <90 mm Hg |
Yes/No |
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Temperature <35°C or ≥40°C |
Yes/No |
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History of: |
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Neoplastic disease |
Yes/No |
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Congestive heart failure |
Yes/No |
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Cerebrovascular disease |
Yes/No |
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Renal disease |
Yes/No |
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Liver disease |
Yes/No |
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If any "Yes", then proceed to Step 2 |
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If all "No" then assign to Risk Class I |
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Step 2: Stratify to Risk Class II vs III vs IV vs V |
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Demographics |
Points Assigned |
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If Male |
+Age (yr) |
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If Female |
+Age (yr) - 10 |
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Nursing home resident |
+10 |
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Comorbidity |
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Neoplastic disease |
+30 |
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Liver disease |
+20 |
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Congestive heart failure |
+10 |
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Cerebrovascular disease |
+10 |
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Renal disease |
+10 |
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Physical Exam Findings |
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Altered mental status |
+20 |
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Pulse ≥125/minute |
+10 |
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Respiratory rate >30/minute |
+20 |
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Systolic blood pressure <90 mm Hg |
+20 |
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Temperature <35°C or ≥40°C |
+15 |
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Lab and Radiographic Findings |
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Arterial pH <7.35 |
+30 |
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Blood urea nitrogen ≥30 mg/dl (9 mmol/liter) |
+20 |
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Sodium <130 mmol/liter |
+20 |
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Glucose ≥250 mg/dl (14 mmol/liter) |
+10 |
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Hematocrit <30% |
+10 |
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Partial pressure of arterial O2 <60mmHg |
+10 |
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Pleural effusion |
+10 |
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∑ <70 = Risk Class II |
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∑ 71-90 = Risk Class III |
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∑ 91-130 = Risk Class IV |
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∑ >130 = Risk Class V |
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(http://en.wikipedia.org/wiki/Pneumonia_severity_index)
The CURB-65 scale is simpler to determine pneumonia severity; however, it is less sensitive than the PSI. Clinicians should assign 1 point for each criteria met by the patient.
If the individual scores 0-1 points, outpatient treatment is appropriate. 2 points indicates hospitalization and inpatient treatment. Greater than or equal to 3 points warrants inpatient treatment in the ICU.
If it is appropriate to treat pneumonia in the outpatient setting, treatment is dictated by the individual's comorbidities and recent exposure to antibiotics.
1st line: previously healthy patients with no antibiotic use in the last 6 months
2nd line: outpatients with comorbidities(chronic heart, lung, liver, renal diseases; diabetes; alcoholism; cancer; asplenia) OR antibiotic use in the last 3 months:
Non-ICU inpatients can be treated with the same regimen listed as "second line" treatment. All ICU patients with be treated with combination therapy. Historically, CAP patients have been treated with 10-14 days of antiomicrobials; however, recent research shows that 7 days of antibiotics may be equally effective (Watkins & Lemonovich, 2011).
We will now do a case study to test your understanding of the content discussed above. Click "next" to continue.
Kathy Peters is a 63 y.o. patient that presents to your urgent care office today with a history of coughing and wheezing for the past 5 days. Originally, she thought she was getting a cold; however, her symptoms have been getting worse, and she states she has never felt this "wiped out" from a cold. She has come to see you today because she feels like she has become more short of breath over the past 24 hours.
Kathy is triaged to a room, and the nursing assistant takes her vitals.
BP: 110/80, HR: 96, RR: 26, T: 101.6, SpO2: 94%, Ht: 5'5", Wt: 130lbs
You go in to see Kathy. She tells you that she started feeling sick approximately 5 days ago. It started with a dry cough; however, over the past couple days she has expectorated some clear, and more recently, thicker rust-colored, mucous. She denies frank blood in her sputum. She notices some wheezing after coughing spells. This morning, Kathy woke up in a "coughing fit" and she said she felt some sharp pain in her chest. She rates the pain a 5/10 when it occurs. Kathy has felt feverish over the past few days; she sometimes gets the "chills." Her highest temperature was 102 degrees. She has taken Tylenol 650mg prn for fever with some relief. The last time she took Tylenol was last night before bed. She has been increasingly fatigued over the past several days; she states she feels like she was "hit by a bus." She denies headache, nausea, vomiting, and diarrhea. Her appetite has been decreased ever since she started feeling sick.
Patient complains of increasing fatigue and malaise. Denies recent weight loss/ gain. Denies headache, sinus pressure, changes in vision/ hearing, eye/ear pain, dizziness, vertigo, and neck tenderness. States throat feels scratchy from coughing. Denies palpitations, syncope, each bruising and bleeding, and edema. Feels short of breath at rest after coughing and with activity. Denies history of lung disease including asthma and COPD. Denies abdominal discomfort. Denies history of mental illness, including anxiety and depression.
Past medical and surgical history: osteopenia (2011), hypertension (2004); had hysterectomy at age 41 for uterine fibroids. Denies recent hospitalizations. No known exposure to illnesses.
Allergies: denies allergies to food and medications; states she might have mild seasonal allergies, but this has never been diagnosed
Medications:
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Medication/Dose/Route |
Time/duration |
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Tylenol 650mg PO |
Q4-6 hours prn |
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Lisinopril 10mg PO |
Q day |
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Calcium 1000mg and Vitamin D 800 units PO |
Q day |
Social history: Patient works as a bank teller at Chase full-time. Lives at home alone; husband died from MI approximately 10 years ago. Not currently sexually active. Has 2 children that live out of state. Tries to walk for 15-30 minutes 3-5 days a week; however, has not been walking recently related to being sick. States she drinks wine occasionally on the weekends. Denies use of tobacco products and recreational drugs. States she is a never-smoker.
Question 1.
General: Patient appears in mild distress from persistent cough and voice sounds congested. Appears fatigued. Adequate hygiene and posture; generally healthy for age except for recent illness.
HEENT:
Head and neck: Hair is evenly distributed over scalp, no alopecia or nits. Face and neck appear symmetrical. Skin is dry and intact except for mild errythema around the nasal folds, no drainage, crusting, or lesions visualized. No c/o pain/tenderness upon palpation of frontal and maxillary sinuses. No cervical lymphadenopathy palpated.
Eyes: Skin around is eyes pink, dry, and intact without edema. Conjunctiva pink and moist. Sclera white, capillaries intact. PERRLA. Red reflex visualized bilaterally with ophthalmoscope; retinal background is yellow, capillaries are well-defined without evidence of hemorrhage; no bulging or cupping of optic disc visualized bilaterally.
Ears: Skin is pink, dry, and intact without edema. Denies tenderness upon palpation. Ears visualized with otoscope; ear canals are pink, dry, and intact with mild cerumen; tympanic membranes are pearly gray, no bulging or discharge visualized.
Nose: Symmetrical, midline of patient's face. Skin slightly errythematous under folds. Nostrils patent bilaterally. Nasal mucosa and inferior turbinates errythematous, moist, and intact bilaterally. Mild amount of white nasal drainage visualized.
Mouth/ Throat: Lips are pink and mildly chapped. Oral mucosa, tongue, gums, and teeth intact. Posterior pharynx mildly errythematous with some cobblestoning; uvula is midline. No tonsillar edema visualized.
Lungs: Chest expansion symmetrical, respirations appeared unlabored and even. Intermittant moist cough followed by short periods of tachypnea. Resonance percussed over upper chest; area of dullness percussed over right lower lobe. Increased fremitus palpated in left lower lobe. BS are clear bilaterally in upper lobes. Expiratory wheezing, rales, and diminished BS auscultated right lower lobe. BS clear and diminished in left lower lobe.
Heart: Heart rate and rhythm are regular. No murmurs, clicks, rubs, or adventitious sounds auscultated. Skin in all 4 extremities is pink, warm, dry, and intact.
Based on Ms. Peters' symptoms and physical exam, you decide to get a chest xray. You have a very skilled technician in your office, and she returns to you with the results in minutes. The images are below:
You diagnose Ms. Peters with pneumonia based on the plain films above.
Show/hide comprehension question...
Out of the pathogens listed, please select the microbe that is most likely cause lobar pneumonia:
Show/hide comprehension question...
While you know labs are not routinely collected in all case of community-acquired pneumonia, you have a speedy lab in your office, and you want to make sure that you are treating Kathy appropriately. You decide to collect a comprehensive metabolic panel. Her results are listed below:
Comprehensive Metabolic Panel:
Gluc: 93 mg/dL
BUN: 18 mg/dL
Creatinine: 1.05 mg/dL
eGFR: >60 mL/min
eGFR-AfAm: >60 mL/min
Na+: 139 mmol/L
K+: 4.4 mmol/L
Cl-: 107mmol/L
CO2: 33 mmol/L
Ca++: 9.2 mmol/L
Gap: 12
Osmo: 281 mOsm/kg
ALT: 33 IU/L
AST: 17 IU/L
ALK PH: 77 IU/L
In order to determine how you are going to treat Ms. Peters, you need to figure out if her pneumonia can be safely managed in the outpatient setting. Being the diligent clinician that you are, you determine her risk according to both the PSI and the CURB-65.
You access the PSI through the following government website:
http://pda.ahrq.gov/clinic/psi/psicalc.asp
(please note: you did not test a hematocrit, so assume that K.P.'s hct is normal)
Show/hide comprehension question...
The CURB-65 scale is listed below.
Mrs. Peters' CURB-65 score is: 0
Show/hide comprehension question...
You feel safe treating Ms. Peters on a outpatient basis. The next step is to determine appropriate antibiotic treatment. You ask Kathy is she has been treated with antibiotics in the last 3-6 months and she says no. She has no known allergies to antiobiotics. You also check her past medical history for co-morbidities.
Show/hide comprehension question...
Show/hide comprehension question...
Per the recommendations, you choose to treat K.P. with a macrolide. You choose azithromycin because Kathy will only have to take it for 5 days; this increases the probability of compliance. You intruct Kathy to take two pills on the first day followed by 1 pill/day for the following 4 days. Because pneuomonia is a serious illness, you write Ms. Peters off of work for the remainder of the week. You ask her to schedule an appointment with her PCP at the beginning of next week for follow-up. You explain that you want to make sure she is doing better; her age can put her more at risk for complications. She asks you if another chest xray should be obtained at her next visit. You explain that an xray is not needed until 6-8 weeks after treatment because it can take awhile for the lungs to recover and appear normal on chest film. You tell her to call your urgent care office if she is not starting to feel better in the next 48-72 hours or if she is getting worse.
The following week, you decide to call Kathy at home to make sure she is doing okay and that she has followed up with her PCP. She states she is feeling a lot better and she just saw her PCP earlier in the day. She thanks you for being such a great clinician and states she will definitely come back to your office if she has an urgent concern down the line!
Marrie, T. J. Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults. In D.S. Basow (Ed.), UpToDate. Retrieved from: http://www.uptodate.com.proxy.lib.ohio-state.edu/
McCance, K. L. & Heuther, S. E. (2010). Pathophysiology: The biologic basis for disease in adults and children. St. Louis, MO: Elsevier.
Miskovich-Riddle, L. & Keresztes, P.A. (2006). CAP management guidelines. The Nurse Practitioner, 31(1), 43-53.
Watkins, R. R. & Lemonovich, T.L. (2011). Diagnosis and managment of community-acquired pneuomonia in adults. American Family Physician, 83(11), 1299-1306.