NU-664B Discussion 1 Hispanic Nondocumented Patient with Acute Illness
NU-664B Discussion 1 Hispanic Nondocumented Patient with Acute Illness
1. Community acquired pneumonia (CAP) – The is the most likely diagnosis for this patient. Subjective findings for this patient include many of the symptoms that are commonly reported in CAP including cough, fatigue, fever, chills, and sore throat (Dunphy et al.,2019). This patient has risk factors for pneumonia which include age greater than 65, the fact that she is a smoker, the fact that she has not been immunized against pneumonia, her asthma history, and the fact that she lives with extended family including elderly and infants (Mendez-Brich et al., 2019). The fact that she has hemoptysis also supports the diagnosis of pneumonia because one of the most common causes of hemoptysis is respiratory infections such as pneumonia ( O’Gurek & Choi, 2022). Annually CAP develops in 5 million people in the United States ( Dunphy et al., 2019). Worldwide CAP is one of the most commonly diagnosed illnesses (Klompas, 2023). Due to its common incidence CAP is the leading diagnosis in this case and would be confirmed with a chest xray.
2. Tuberculosis (TB)- TB needs to be considered in this case due to the fact that the patient recently immigrated from a Latin American country and did not receive BCG vaccination ( Dunphy et al., 2019). This diagnosis also needs to be considered because when considering the worldwide population as a whole TB is the most common cause of hemoptysis ( O’Gurek & Choi, 2022). According to Wei et al. (2020) the incidence of TB in Columbia is 10-99 per 100,000 population per year. Factors that make the diagnosis of TB less likely in this case is that the patient is not immunocompromised with contributing diagnosis such as HIV or the use of immunosuppressive medications (Dunphy et al.,2019). Sputum gram stain and culture and chest xray would help to rule in or out this diagnosis.
3. Influenza- Influenza is another diagnosis to consider because its classical presentation includes fever, chills, and nonproductive cough (Dunphy et al.,2019). A risk factor in this case is that the patient did not receive influenza vaccination (Dunphy et al.,2019). This was placed lower on the list of differentials due to the fact that the patient reports these symptoms have been going on for 2 weeks. Typically, in influenza the cough is present early in the course of illness. Also the fever typically lasts 3-5 days (Dunphy et al.,2019).
4. Covid-19- Covid-19 needs to be included in the differential diagnosis because the patient has many of the symptoms classically identified in this illness such as fever, cough, sore throat, breathlessness, and fatigue (Singhal,2020). The fact that she has known exposure to other people who are acutely ill and lacks vaccination place her at risk for Covid-10 (Singhal,2020). Negative PCR testing will rule out the diagnosis (Pascarella et al.,2020).
Primary Differential Diagnosis: Community acquired pneumonia (CAP)
ibuprofen [Motrin, Advil] 400 to 600 mg PO every 6 to 8 hours as needed for sore throat, myalgias, or headache.
acetaminophen [Tylenol] 650 mg PO every 4 to 6 hours as needed for sore throat, myalgias, or headache.
guaifenesin 200 to 400 mg PO every 4 hours as needed for cough
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Albuterol hfa 90 mcg inhaler 2 puffs every 4 hours as needed for sob
Augmentin 875 mg twice a day orally for 5 days
Azithromycin 500 mg orally day 1, then 250 mg daily days 2-5
(Dunphy et al.,2019)
Advise the patient to rest. Drink plenty of fluids. Gargle with salt water to help alleviate the sore throat. Discuss appropriate hygiene including washing the hands frequently to avoid transmission to others and to avoid future infections (Dunphy et al, 2019).
Influenza PCR to rule out influenza. Covid-19 PCR to rule out Covid-19. Chest xray to confirm diagnosis of pneumonia and then in this case I would do follow up chest xray film in 4 weeks to check for resolution due to her increased lung cancer risk due to smoking and her report of hemoptysis ( Klompas,2023). CBC and CMP to evaluate for any signs of sepsis which may require hospitalization such as leukocytosis, abnormal renal, or liver function (Klompas, 2023). In this case there is a suspicion for TB so sputum culture with gram stain would be obtained to help rule this out (Dunphy et al.,2019).
No Specialist referral is indicated at this time
Patient education: 1. The patient should receive the influenza vaccine annually. 2. The patient should receive the Prevnar13 pneumonia vaccine once she is feeling better and then one year later receive the pneumovax23. 3. She should be encouraged to be vaccinated against covid-19. 4. She needs to be counseled on smoking cessation 5. I would instruct the patient to get plenty of rest. 6. I would instruct the patient to drink plenty of fluids. 7. I would instruct the patient to use humidified air. 8. I would advise the patient to go to the emergency room with worsening symptoms, any difficulty breathing, or confusion 9. I would instruct the patient to take the antibiotic exactly as prescribed and finish the entire course even if feeling better 10. Use saline nasal spray to help with sore throat. 11. Use topical anesthetic spray for sore throat such as chloraseptic.
(Dunphy et al.,2019).
I would complete wellness check on patient in 48-72 hours to make sure symptoms were improving. I would advise the patient to seek care at the emergency room if shortness of breath or wheezing developed. I would advise the patient to schedule an office visit in 1 week to follow up on symptom resolution and then 4 weeks to review follow up xray films (Dunphy et al.,2019).
Health Maintenance: I would counsel the patient on the importance of smoking cessation. The patient should receive the influenza vaccine annually. The patient should receive the Prevnar13 pneumonia vaccine once she is feeling better and then one year later receive the pneumovax23. She should be encouraged to be vaccinated against covid-19.
Social Determinants of Health: Due to the fact that all of the patients family members are undocumented residents of the united states it would be important to recognize that this population may face lack of culture competency when receiving healthcare ( Chang,2019). It would be important to make sure that there are translation services available so that the patient feels comfortable and is able to better share their story about their symptoms and so that they can understand the treatment plan. Written instructions on prescriptions should be offered in the patients preferred language. It would be important for the health care provider to realize that the patient may have concerns about disclosing their status due to fears of deportation. There may also be challenges related to lack of health insurance, poverty, housing insecurity, and food insecurity ( Chang,2019). I would inquire about these types of challenges and connect the patient with appropriate community resources to assist. It would also be important to consider the cost of medication and testing and base treatment decisions off of this.
Chang, C. D. (2019). Social determinants of health and health disparities among immigrants and their children. Current Problems in Pediatric and Adolescent Health Care, 49(1), 23–30. https://doi.org/10.1016/j.cppeds.2018.11.009
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th
ed.). F. A. Davis Company.
Klompas, M. (2023). Clinical evaluation and diagnostic testing for community-acquired
pneumonia in adults. Uptodate. Retrieved January 21,2023, from https://www.uptodate.com/contents/clinical-evaluation-and-diagnostic-testing-for-community-acquired-pneumonia-in-adults
Méndez-Brich, M., Serra-Prat, M., Palomera, E., Vendrell, E., Morón, N., Boixeda, R., Cabré, M., & Almirall, J. (2019). Social Determinants of community-acquired pneumonia: Differences by age groups. Archivos De Bronconeumología, 55(8), 447–449. https://doi.org/10.1016/j.arbres.2018.12.012
O’Gurek, D., & Choi, H. Y. J. (2022). Hemoptysis: Evaluation and management. American Family Physician , 105(2), 144–151.
Pascarella, G., Strumia, A., Piliego, C., Bruno, F., Del Buono, R., Costa, F., Scarlata, S., & Agrò, F. E. (2020). COVID-19 diagnosis and management: a comprehensive review. Journal of internal medicine, 288(2), 192–206. https://doi.org/10.1111/joim.13091
Singhal T. (2020). A Review of Coronavirus Disease-2019 (COVID-19). Indian journal of pediatrics, 87(4), 281–286. https://doi.org/10.1007/s12098-020-03263-6
Wei, M., Yongjie Zhao, Zhuoyu Qian, Biao Yang, Xi, J., Wei, J., & Tang, B. (2020). Pneumonia caused by Mycobacterium tuberculosis. Microbes and infection, 22(6-7), 278–284. https://doi.org/10.1016/j.micinf.2020.05.020
Four differential diagnoses:
Influenza (flu) is an acute respiratory virus that is caused by influenza A or B (Dolin, 2022). This is considered as a possible diagnosis because of the symptoms of fever, nonproductive cough, and myalgias (Dolin, 2022). Other symptoms that are common are sore throat and headache (Dolin, 2022). I would swab to rule this one out, but it can be ruled out since the patients illness has been going on for the past month. Flu typically lasts anywhere from 5-7 days.
2. Bacterial Pneumonia.
Bacterial pneumonia is the lead diagnosis because of the symptoms she is describing. She has had a cough for almost a month, that is very congested but nonproductive. There is a presence of chest pain, especially when coughing. Other symptoms common in a pneumonia presentation are sudden onset of fever, fatigue, chills, and myalgia (Dunphy et al., 2019). This patient is 75 years old, so if she does have pneumonia she could have mental confusion and increased weakness.
COVID-19 is the respiratory disease caused by SARS-CoV-2. This diagnosis should be considered because of the severity of symptoms. Shortness of breath is not typically present in flu. Along with her symptoms (sore throat, headache, fever, chills, myalgia, chest pain, SOB, non-productive cough), she is at high risk for severe disease due to her advanced age and chronic medical condition (asthma) (Cohen & Gebo, 2022). COVID-19 can be ruled out or confirmed with a SARS-CoV-2 PCR nasal swab. When dyspnea and increasing chest discomfort/tightness are experienced, those symptoms are indicative of pulmonary involvement (Cohen & Gebo, 2022).
This is a must not miss diagnosis. She has had a cough and has felt unwell for about a month. Her body temperature in office in 102, she has lost a significant amount of weight from not eating, and is only voiding a few times a day. Because she is so ill-appearing, I would want to get labs for a septic work up. Labs would include CBC, CMP, serum lactate, and blood cultures (Neviere, 2022). Then giving an IM dose of ceftriaxone 1G in office. A broad-spectrum antibiotic like ceftriaxone has the potential to cover many bacteria and can jump-start eradicating the infection if it has gone to her blood. Blood cultures would take a couple of days, but the rest of the lab work would be returned quickly. Depending on the results, she may need to be admitted to the hospital for IV antibiotics and fluid resuscitation. In the outpatient setting, adults with comorbidities and no recent antibiotic use should be prescribed a cephalosporin and a macrolide, or Augmentin and doxycycline (Hollier, 2021).
Diagnosis: Bacterial Pneumonia
Ceftriaxone 1gram IM. Ceftriaxone 1gm given IM, STAT once.
Azithromycin- Take 2 (500mg) tablets by mouth on day 1, then take 1 (250mg) tablet once daily for 4 days.
Ibuprofen 200mg tablets. Take 2-3 tablets (400-600mg) by mouth every 6-8 hours for pain and fever control.
Acetaminophen 325mg tablets. Take 1-2 tablets (650mg) by mouth every 4-6 hours for body aches and fever control. Do not exceed 4000mg daily.
Ventolin HFA 17-g cannister. 200 actuations. Use 2 puffs every 4-6 hours for bronchospasm, or 1 puff every 4-6 hours during acute illness. Shake well before use.
Benzonatate 100mg gel capsules. Take 1-2 capsules (100-200mg) by mouth 3 times a day for cough.
-increase fluid intake 1-2L per day
-rest, but be sure to move around several times a day
-sleep with cool-mist humidifier
-CBC, CMP, Lactic Acid, and 2 sets of blood cultures.
-SARS-CoV-2 PCR Nasal swab (Cohen & Gebo, 2022).
-Influenza antigen nasal swab (Dolin, 2022).
Referrals/Interprofessional Communications: No referrals are needed for this patient at this time.
-Increase your intake fluids. Water is best, but hydration is your goal. Drink something with electrolytes like Gatorade.
-Reduce your activity until your symptoms start improving.
-Alternate Ibuprofen and Acetaminophen every 3 hours. Example: Take ibuprofen @3pm and acetaminophen @ 6pm. Alternating the medications will help with body aches, chest pain, and better control fevers.
-Azithromycin is only a 5-day course but continues working for 10 days. This is why follow-up will be in one week if you are not improving. Avoid aluminum or magnesium containing antacids, this can reduce the effectiveness of the antibiotic. Take the WHOLE course of antibiotics even if your symptoms improve in 2-3 days. Not taking the whole course can lead to recurrent infection and antibiotic resistance.
-the Benzonatate is a cough suppressant medication. These will be most beneficial at night when trying to sleep.
-Ventolin is likely similar to the rescue inhaler you had back in Honduras. It is to be used for duration of your symptoms to help reduce dyspnea and cough. This medication can cause an increased heart rate, and this is normal. Make sure you shake well before each use (Hollier, 2021).
Follow-up: Follow-up in one week if you are not better. You may need different antibiotics. We will call you if the blood cultures show that you need a different antibiotic to treat the pneumonia. You should start to feel improvement of your symptoms in 48-72 hours. If your symptoms worsen, you have troubles breathing, increased chest pain, mental confusion, or fever not controlled by fever-reducing medications, you should go to the nearest ER. I would like to see you back in 4-6 weeks for a chest x-ray to ensure the infection is completely gone (Hollier, 2021).
Health maintenance item: COVID-19 and pneumococcal pneumonia vaccine.60-7
These are important in preventing more severe disease and hopefully prevent hospitalization. Getting these vaccines will also help protect your loved ones living with you. You have a higher risk of suffering from more severe complications following catching a virus because of your history of asthma (Dunphy et al., 2019).
Cohen, P., & Gebo, K. (2022). COVID-19: Evaluation of adults with acute illness in the outpatient setting. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/covid-19-evaluation-of-adults-with-acute-illness-in-the-outpatient-setting?search=COVID&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H499088308
Dolin, R. (2022). Seasonal influenza in adults: Clinical manifestations and diagnosis. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/seasonal-influenza-in-adults-clinical-manifestations-and-diagnosis?search=influenza&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: The Art and Science of Advanced Practice Nursing- An Interprofessional Approach. (5th ed.). F. A. Davis Company.
Hollier, A. (2021). Clinical Guidelines in Primary Care. (4th ed.). Advanced Practice Education Associates.
Lexicomp. (1978-2023). Benzonatate: Drug information. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/benzonatate-drug-information?search=tessalon%20perles%20adult&source=panel_search_result&selectedTitle=1~7&usage_type=panel&kp_tab=drug_general&display_rank=1#F140001
Neviere, R. (2022). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/sepsis-syndromes-in-adults-epidemiology-definitions-clinical-presentation-diagnosis-and-prognosis?search=sepsis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H21