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Case Study: What’s Causing This Cough?

Nurses Article CSI   (2,272 Views | 19 Replies | 632 Words)

SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

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How well do you know your way around a cough?

A new case study in which the patient, H.T. an 82-year-old Hispanic man presents to his primary care clinic with cough, malaise and confusion. How well do you know your way around a cough? Is it a cold, a virus, a bacterial infection? Maybe it’s TB? Pneumonia? Figure it out before it’s too late. You are reading page 2 of Case Study: What’s Causing This Cough?. If you want to start from the beginning Go to First Page.

emtb2rn has 21 years experience as a BSN, RN, EMT-B and specializes in Emergency.

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All of the above. Add a cmp.  If he was febrile, draw lactate & procalcitonin. 

Edited by emtb2rn

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 56 Articles; 357 Posts; 19,068 Profile Views

UPDATE ON MR. T!

Your first order of business is to tell the granddaughter to have Mr. T stop taking the tea, or at least to leave out the Tequila! 

Use https://www.drugs.com/interaction/list/ to check drug interactions. Noting that ETOH can cause BP to drop when taken with atenolol and HCTZ. ETOH and aripiprazole can cause dizziness, confusion and drowsiness and of course taking ETOH with ASA can irritate the lining of the stomach and increase the risk for stomach ulcers.

Gordolobo tea is made with Mullein flowers. You can read more about it here https://www.drugs.com/npc/mullein.html

There isn’t a lot of information out there about interactions, dosing or side effects and minimal scientific support that it works.

Review of Systems: only abnormal values presented

  • Difficult to conduct due to patient’s mental status (lethargy present)
  • Caregiver states difficulty with sleeping due to cough
  • No episodes of emesis observed, but decrease in appetite
  • Caregiver denies dysphagia, rashes and hemoptysis
  • Skin: Warm and clammy, (-) for rashes
  • HEENT: watery eyes, nares slightly flared, green, purulent discharge visible, ears with slight serous fluid behind tympanic membrane, pharynx erythematous with purulent post-nasal drainage, mucous membranes inflamed and moist.
  • Neck: mild bilateral cervical adenopathy
  • Lungs/Thorax: Breathing labored with tachypnea, RUL and LUL reveal crackles and diminished breath sounds, RLL and LLL reveal absence of breath sounds and dullness to percussion.
  • Musculoskeletal: strength 1/5 right side, 4/5 left side
  • Neuro:  Oriented to self only

Vital signs:

  • BP 142/81 LA sitting, no orthostatic changes prehypertension 140/90
  • HR 90, regular (60-90 normal)
  • RR 31 and labored (12-14 normal)
  • T 98.2oF
  • HT 5’5”
  • WT 105 lbs
  • BMI 17.5 underweight
  • O2 saturation 86% on room air

Laboratory Test Results:

  • Na 141 meg/L 135-145
  • K 4.5 meq/L 3.5-5
  • Cl 105 101-112
  • HCO3 29 meq/L 22-32
  • BUN 16 mg/dL8-20
  • Cr 0.9 mg/dL 0.6-1.2
  • Glucose, fasting 138 mg/dL  60-110
  • Mg 1.7 mg/dL 1.8-3
  • PO4 2.9 mg/dL 2.5-4.5
  • Hb 14.7 g/dL (males 13.6-17.5
  • Hct 42.4% (males 39-49)
  • WBC 15,200/mm3 4,800-10,800
    • Neutros 82% 57-67
    • Bands 4% 0-1
    • Lymphs 10% 25-33
    • Monos 3% 3-7
    • Eos 1% 1-4

Arterial Blood Gas

  • pH 7.5 7.35-7.45
  • PaO2 59 mm Hg room air 83-108
  • PaCO2 25 mm Hg 35-45

Imaging: Chest X-ray shows consolidation of inferior and superior segments of RLL and LLL. Developing consolidation of RUL and LUL

Pleural effusion (-)

Heart size WNL

Sputum analysis: Gram stain: TooNumerousToCount/TNTC neutrophils, some epithelial cells, negative for microbes

Try this algorithm for respiratory problems: https://accessmedicine.mhmedical.com/content.aspx?bookid=1088&sectionid=61697703

Remember, don't post the answer here, but I'm sure you're on the right track. Instead, post your answer in the Admin Help Desk

Next update in a few days will have help for how to nail down specifics.

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sirI has 30 years experience as a MSN, APRN, NP and specializes in Education, FP, LNC, Forensics, ED, OB.

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🔍Members have started posting in the Help Desk to register their guesses. 🔎

If you have a guess regarding the diagnosis, post your answer in the Admin help Desk.

 

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sirI has 30 years experience as a MSN, APRN, NP and specializes in Education, FP, LNC, Forensics, ED, OB.

15 Followers; 19 Articles; 13,254 Posts; 139,715 Profile Views

REMINDER 👋

Members are submitting their guesses in the Help Desk.

@SafetyNurse1968 will post another update very soon. 👌

If you have a guess regarding the diagnosis, post your answer in the Admin Help Desk.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 56 Articles; 357 Posts; 19,068 Profile Views

Mr. T has community acquired pneumonia (CAP), but what kind? How severe is it? Does he need to go to the hospital?

Refresher - pneumonia is a common lung infection where alveoli become inflamed. They can fill with fluid, pus, and cellular debris. It can be caused by viruses, fungi, or bacteria, but it looks like Mr. T. has bacterial pneumonia, the most common type of CAP. 

Bacterial vs. viral pneumonia: How to tell the difference

The two most common causes of pneumonia are bacteria and viruses. The flu is one of the most common causes of viral pneumonia in adults, though post-flu complications can also cause bacterial pneumonia. Viral pneumonia is more likely to affect healthy people with strong immune systems. Bacterial pneumonia can be more aggressive and difficult to treat than viral pneumonia. In bacterial pneumonia, there will likely be a much more visible presence of fluid in the lungs than viral pneumonia. Bacterial pneumonia is also more likely to enter the blood stream and infect other parts of the body.

What color is my mucus?

You may have read that you can tell what pathogen you’re infected with by the color of the mucus. White means a cold, yellow or green are bacterial, but that’s actually not true. Both viral and bacterial upper respiratory infections can cause similar changes to the type and coloration of nasal mucus. During a common cold, nasal mucus may start out watery and clear, then become progressively thicker and opaque, with a yellow or green tinge. 

The timing of symptoms may offer a clue as to the type of germs present. Thick, colored nasal mucus more often occurs at the beginning of a bacterial illness, rather than several days into it, as occurs with a viral infection. In addition, symptoms due to a bacterial infection often last more than 10 days without improvement.

In a few cases, a bacterial infection may develop on top of a viral cold, in which case symptoms may get better and then worse again. Under these circumstances, an antibiotic may lessen the severity of symptoms and shorten the duration of the illness.

Additional Questions - PLEASE DO POST THE ANSWERS TO THESE HERE (yes, really, you can post them here): 

  1. Admit to hospital for treatment?
  2. 30-day mortality probability?
  3. Any signs supporting “double pneumonia?”
  4. How many risk factors predispose this patient to pneumonia?
  5. How many clinical manifestations are consistent with pneumonia?

Try this tool to answer: the Pneumonia Severity of Illness site will calculate mortality risk and hospitalization recommendation.

https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap

Use the references below to determine the likely pathogen and rationale, then come to the Admin Help Desk to register and/or amend your guess(s).

SafetyNurse1968 will return to the CSI with a final update soon.


References

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tnbutterfly - Mary is a BSN, RN and specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

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Thanks for providing the great references, SafetyNurse.  

Let's hear from the members for answers to the questions SafetyNurse has posted.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 56 Articles; 357 Posts; 19,068 Profile Views

This patient has pneumococcal pneumonia caused by Streptococcus pneumonia.

The most common symptoms of bacterial pneumonia are:

  • a cough with thick yellow, green, or blood-tinged mucus
  • stabbing chest pain that worsens when coughing or breathing
  • sudden onset of chills severe enough to make you shake
  • fever of 102-105°F or above (fever lower than 102°F in older persons)

Other symptoms that may follow include:

  • headache
  • muscle pain
  • breathlessness or rapid breathing
  • lethargy or severe fatigue
  • moist, pale skin
  • confusion, especially among older persons
  • loss of appetite
  • sweating

Older adults will share all the symptoms with younger adults but are much more likely to experience confusion and dizziness. Older adults may also be less likely to have a fever.

Bacteria pneumonia is caused by bacteria that works its way into the lungs and then multiplies. It can occur on its own or develop after another illness, like a cold or the flu. 

Types of bacteria

Streptococcus pneumonia is the leading cause of bacterial pneumonia. It can enter your lungs through inhalation or through your bloodstream. There is a vaccination for this type.

Haemophilus influenzae is the second most common cause of bacterial pneumonia. This bacterium may live in your upper respiratory tract. It doesn’t usually cause harm or illness unless you have a weakened immune system.

Other bacteria that can cause pneumonia include:

  • Staphylococcus aureus
  • Moraxellaca tarrhalis
  • Streptococcus pyogenes
  • Neisseria meningitidis
  • Klebsiella pneumoniae

Environmental and lifestyle risk factors

  • smoking
  • working in an environment with a lot of pollution
  • living or working in a hospital setting or nursing facility
  • Medical risk factors
  • recent viral respiratory infection
  • difficulty swallowing 
  • chronic lung diseases
  • weakened immune system 

Age groups

People over the age of 65 and children 2 and younger are at a higher risk for developing pneumonia. Pneumonia for these groups can be life-threatening.

How is bacterial pneumonia diagnosed?

  • Auscultate lungs
  • CBC
  • Blood culture
  • Sputum culture
  • Chest X-rays 

How do you treat bacterial pneumonia?

Most cases can be treated at home with antibiotics. A healthy person may recover within one to three weeks. Someone with a weakened immune system may take longer.

Hospital care

Some cases of bacterial pneumonia will require hospitalization for treatment. Young children and the elderly are more likely to need intravenous antibiotics and rehydration as well as respiratory therapy.

Complications

Without treatment, pneumonia may develop into:

  • organ failure
  • difficulty breathing
  • pleural effusion
  • lung abscess

How can you prevent bacterial pneumonia?

Bacterial pneumonia itself is not contagious, but the infection that caused bacterial pneumonia is contagious. It can spread through coughs, sneezes, and contamination on objects. Practicing good hygiene can help prevent the spread of pneumonia or the risk of catching it.

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AN Admin Team has 50+ years experience.

2 Articles; 186 Posts; 18,299 Profile Views

Here are the responses from members who came to the Admin Help Desk to submit their diagnoses for the 4th Case Study Investigation (CSI): What's Causing This Cough?.

Thank you to all who participated. We hope you enjoyed the CSI.

CSI #5 is coming very soon!

@DextersDisciple 

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COPD exacerbation due to Pneumonia?

@Susie2310

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My guess for the diagnosis for the article "What's causing this cough?" is pneumonia with sepsis.

@NRSKarenRN

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URI progressing to Exac COPD with pneumonia -? aspiration pneumonia, failure to thrive as underweight. Needs homecare referral for followup education meds, disease process. 

@Cb2015

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Diagnosis guess pneumonia complicate by respiratory alkalosis

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