BACTERIAL PNEUMONIA
Order Instructions
CASE STUDY
HPI
Edwin is a 69 year old male who comes in to the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. He didn’t take his temperature because he did not have a thermometer but he “felt hot”. He says he is coughing up a little phlegm. He states that it hurts when he takes a deep breath. He also states that his appetite has not been very good. He has been taking Tylenol with minimal relief. He has also been drinking teas to try to break up the phlegm.
Edwin is a nonsmoker and non drinker. He has been very healthy and has no medical problems. He has never had surgery.
EXAMINATION
On exam, his vital signs are: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94%.
Exam reveals decreased rales and rhonchi, more pronounced in the left lower lung fields, with increased fremitus and dullness to percussion.
DIAGNOSTIC TESTING
Chest x-ray reveals a consolidation in the left lower lobe.
DIAGNOSIS
This appears to confirm that he has PNEUMONIA.
THE ASSIGNMENT TO BE COMPLETED
PART A
Describe the patient’s diagnosis (PNEUMONIA) and why. Think about clinical guidelines that might support the diagnosis.
PART B
Use the template below to create management plan for two primary diagnoses related to this case study. (The diagnosis is PNEUMONIA)
MANAGEMENT PLAN TEMPLATE: (PLEASE USE BULLET POINTS)
Address the following:
1. Primary Diagnosis (PNEUMONIA) and ICD-10 code: Also include any procedural codes (CITE REFERENCE)
2. Provide a minimum of three possible differential diagnoses with supporting evidence. (Here are some differential diagnoses that can be used:(Acute bronchitis, Pneumonitis, Heart failure Bronchiolitis, Pulmonary embolus, Pulmonary Tumors, Tuberculosis). List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis
3. Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.
4. Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals.
5. Therapeutic modalities: Pharmacological and Non-pharmacological management.
Pharmacological:
Non-pharmacological:
6. Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
7. Patient education: Explanations and advice given to patient and family members.
8. Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.
9. REFLECTION NOTE: What was your “aha” moment? What would you do differently in a similar patient evaluation?
10. References: (minimum of 3, timely within the last 5 years that prove this plan follows current standard of care).
The assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed within the past 5 years. (Please use 2 from the learning resources below). ThankS.
LEARNING RESOURCES
Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). Elsevier.
Leik, M. T. C. (2018). Family nurse practitioner certification intensive review: Fast facts and practice questions (3rd ed.). Springer Publishing Company.
American Nurses Association. (2020). https://www.nursingworld.org/
American Association of Nurse Practitioners. (2020). https://www.aanp.org/
American Nurses Credentialing Center. (2020). https://www.nursingworld.org/ancc/
Centers for Disease Control and Prevention. (2020). https://www.cdc.gov/
Office of Disease Prevention and Health Promotion. (2020b). Healthy people 2020. https://www.healthypeople.gov/
Office of Disease Prevention and Health Promotion. (2020a). Development of the national health promotion and disease prevention objectives for 2030. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030
World Health Organization. (2020). https://www.who.int/
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