My patient in clinical last week had medical diagnoses in the notes from the admitting physician of medication monitoring, obstructive sleep apnea, chronic airway obstruction, asthma, thryotoxicosis without mention of goiter, pneumonia, malignant neoplasm of colon, and A-fib. She had rhonchi and diminished lung sounds in the lower lobes and rhonchi in the middle and upper lobes. Her WBC was 19.7. She had been in the ER several times in the past month and had been treated with several different antibiotics, but wasn't getting any better. She continued to have fevers and SOB, although she is a COPD patient. All of her urine and blood cultures had come back negative. They seemed to be guessing and just trying different antibiotics. They had tried Azithromyocin, fluconazole, and amoxicillin. When my instructor asked for her medical problem that she was admitted for, I said pneumonia because that's what was written all over in her chart, but my instructor said that she didn't have pneumonia. I have to written a patho card for her and I have no idea what the diagnosis would be. Would it be COPD exacerbation or pneumonia?
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My patient in clinical last week had medical diagnoses in the notes from the admitting physician of medication monitoring, obstructive sleep apnea, chronic airway obstruction, asthma, thryotoxicosis without mention of goiter, pneumonia, malignant neoplasm of colon, and A-fib. She had rhonchi and diminished lung sounds in the lower lobes and rhonchi in the middle and upper lobes. Her WBC was 19.7. She had been in the ER several times in the past month and had been treated with several different antibiotics, but wasn't getting any better. She continued to have fevers and SOB, although she is a COPD patient. All of her urine and blood cultures had come back negative. They seemed to be guessing and just trying different antibiotics. They had tried Azithromyocin, fluconazole, and amoxicillin. When my instructor asked for her medical problem that she was admitted for, I said pneumonia because that's what was written all over in her chart, but my instructor said that she didn't have pneumonia. I have to written a patho card for her and I have no idea what the diagnosis would be. Would it be COPD exacerbation or pneumonia?