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?
Provided by caregiver: "My grandfather is confused and pretty sick. He was up most of the night coughing.”
History of Present Illness:
H.T. is an 82-year-old Hispanic male who is widowed and a retired grocery store owner. His 28-year-old granddaughter lives with him. He uses a walker and takes daily walks in the neighborhood with her. He can perform most ADLs, but his granddaughter prepares his meals. He presents to the clinic with his caregiver who reports that about a week ago, Mr. T. came down with a cold and had a runny, stuffy nose. He visited the curandero and has been drinking gordolobo tea with honey, lemon and a generous dollop of tequila. He appeared to be getting better, but then several days ago he developed a cough. Over the last two days, the cough has become worse and he can't seem to catch his breath. He was confused last night and nearly fell getting out of bed.
General Appearance:
The patient's age is consistent with that reported. He is well-groomed and neat, uses a walker for ambulation and walks with a pronounced limp. He is lethargic, frail and thin oriented to self only. Patient is coughing and using accessory muscles to breathe. Appears uncomfortable and in moderate respiratory distress.
Past Medical History:
Tobacco dependence x 60 years
Chronic bronchitis for 10 years
Urinary overflow incontinence for 10 years
HTN x 5 years, BP averages 140/80 with medication
Mild right hemiparesis caused by CVA 3 years ago
Bipolar x 50 years
Constipation x 6 months
Influenza vaccination 3 months ago
Family History:
(+) for HTN and cancer, (-) for CAD, asthma, DM
Social History:
Lives with granddaughter in his home
Smokes ½ ppd
Some friends recently ill with "colds"
Occasional alcohol use
Medications:
Atenolol 100 mg po QD
HCTZ 25 mg po QD
Aspirin 325 mg po QD
Aripiprazole 15 mg po QD
Combivent MDI 2 puffs QID (caregiver states patient rarely uses)
Albuterol MDI 2 puffs QID PRN
Docusate calcium 100 mg po HS
Allergies:
Penicillin (rash)
Okay, super sleuths, what are all the possible reasons for a cough? What's causing his confusion? I think the most fun way to play is to imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions!
Specializes in Education, Informatics, Patient Safety.
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.
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
Specializes in Education, Informatics, Patient Safety.
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):
Admit to hospital for treatment?
30-day mortality probability?
Any signs supporting “double pneumonia?”
How many risk factors predispose this patient to pneumonia?
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.
Specializes in Education, Informatics, Patient Safety.
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.
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.
URI progressing to Exac COPD with pneumonia -? aspiration pneumonia, failure to thrive as underweight. Needs homecare referral for followup education meds, disease process.
emtb2rn, BSN, RN, EMT-B
2,942 Posts
All of the above. Add a cmp. If he was febrile, draw lactate & procalcitonin.