Carmelita Bautista, a 19-year-old transgender client (DOB: 5/1/2005) who identifies as female (pronouns she/her), presents to the Emergency Department with a productive cough (with green mucus), fever, chills, a loss of appetite, and fatigue for two days

CASE STUDY:
Carmelita Bautista, a 19-year-old transgender client (DOB: 5/1/2005) who identifies as female (pronouns she/her), presents to the Emergency Department with a productive cough (with green mucus), fever, chills, a loss of appetite, and fatigue for two days. The NP performs a physical assessment that reveals crackles in the left lower lobe with lung sounds diminished on the right with no retractions or increased work of breathing. A rapid test indicates that she is negative for influenza, COVID-19, and RSV and a chest X-ray demonstrates consolidation in the left lower lobe. The NP diagnoses the client with bacterial pneumonia and considers appropriate antibiotic therapy knowing that pneumococcal resistance to macrolides is less than 25% in the geographic area.
Past Medical History: None
Allergies: Amoxicillin
Medications: Multivitamin
Social History: She has never smoked cigarettes and does not drink alcohol.
Physical Exam:
• Height: 5 feet 2 inches
• Weight: 110 pounds
• Body Mass Index (BMI): 20.1
• Blood Pressure (BP): 105/67
• Heart Rate (HR): 91
• Respiratory Rate (RR): 21
• Oxygen Saturation (O2 Sat): 96% on RA
• Temperature (TEMP): 101.5 oral
An appropriate prescription for Carmelita is:
Name: Carmelita Bautista
Date Of Birth: 5/1/2005
Date Prescribed: Current Date
Rx: doxycycline (Vibramycin) 100mg
Disp: 10
Sig: Take one tablet by mouth twice daily for five days
Refills (O-4): 0
Dispense as Written:
Generic Substitution Permitted:
• Either Dispense as Written or Generic Substitution Permitted should be checked on every written prescription depending on what is best for each client. Refer to the week 1 lesson for criteria.
Rationale: Amoxicillin is the preferred first-line treatment for outpatient clients with CAP who have no comorbidities. However, this client is allergic to amoxicillin. Doxycycline is also appropriate for treating clients with CAP who have no comorbidities and are receiving outpatient therapy, according to the CPG (Metlay et al., 2019). The client should receive 100mg of doxycycline twice daily (Metlay et al., 2019) for five to seven days (Ramirez, 2023). For this client, treatment is prescribed for five days at this time, pending the client’s reaction to treatment (Ramirez, 2023).

Step 1: Assess the client’s case, the applicable clinical practice guideline (CPG), and the prescription information provided.
Step 2: Answer the discussion prompts below with explanation and detail, providing complete references for all citations. Refer to the lesson for client information.
Include the following sections:
1. Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
a. Describe your assigned client’s situation. Why are they presenting to the clinic? What medications are they currently taking?
b. Assess the applicable clinical practice guideline (CPG) for your assigned client linked on the same page in the lesson where the client case is located. What treatment is recommended by the CPG for your client’s situation?
c. Discuss your personal professional assessment of the client’s situation provided in the scenario. What pharmacological treatment is necessary and why?
d. Reflect on additional questions you have about your assigned client that may influence treatment. What else do you need to know? What follow-up assessments, labs, or conversations are required to ensure optimal health outcomes?

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