Case Study #3
Admitting History
A 79-year-old man was admitted to the hospital because of cough, fever, and a right
lower lobe infiltrate. He was born in Detroit and worked as a truck driver for a dry-cleaning
chemicals company for 51 years. He was always a hard worker and an active member of
Teamsters Local 299.
He started smoking at 14 years of age and averaged about two packs of cigarettes per
day. The patient was last admitted to the hospital 2 years ago for an acute inferior myocardial
infarction. He was treated with medications and recovered quite well. He stopped smoking at that
time. After his myocardial infarction, he continued to manage his daily affairs without difficulty.
He exercised regularly by working in his yard each day, and he power-walked every other day at
the mall.
Then, 4 days before this current admission, the man reported that he began experiencing
“flulike” symptoms. He had chills; a mild fever; and a hacking, nonproductive cough. Although
he was not feeling well, he continued to work in his yard and power-walk at the mall. The
evening before this admission, his friends noted that he was progressively getting worse and
encouraged him to see a doctor. Thinking that he would feel better soon, he stated that if he did
not feel better in a week, he would visit his doctor. The next day, however, the patient was very
short of breath, his cough was more frequent, and he had a temperature of 38.3° C (101° F). At
that point, he drove himself to the hospital.
Physical Examination
On inspection the patient was a well-nourished man in obvious respiratory distress on 2
L/min oxygen by nasal cannula. He was monitored by pulse oximetry. The patient stated that he
was very short of breath. He had a blood pressure of 165/90, heart rate of 120 bpm, respiratory
rate of 33/min, and an oral temperature of 39.5° C (103° F). He demonstrated a frequent, strong
cough. His cough was “hacky” and productive of a small amount of white and yellow sputum.
His skin appeared pale and damp. When the man repeated the phrase ninety-nine, increased
tactile and vocal fremitus was noted over the right lower lung posteriorly. Dull percussion notes
and bronchial breath sounds were noted over the right lower lung regions posteriorly. His oxygen
saturation measured by pulse oximetry (SpO2) was 87%, and his arterial blood gases (ABGs)
were as follows: pH 7.56, PaCO2 24 mm Hg, HCO3– 22 mmol/L, and PaO2 56 mm Hg. His chest
X-ray demonstrated a right lower lobe infiltrate, air bronchograms, and alveolar consolidation
(Figure 3-1). His white blood cell (WBC) count was 21,000/mm3.
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Case Study
2
Figure 3-1 Chest X-ray of a 79-year-old man
1. What disease process should the team suspect that he has?
2. What evidence supports it?
3. What is the interpretation of the current blood gas? Why?
4. What are some immediate actions that he RCP could take?
5. What are some treatment recommendations that the RCP could make?
6 Hours Later
The therapist performing assessment rounds gathered the following clinical information:
The patient stated, “My doctor is too young. I feel worse than when I came in here.” He had a
blood pressure of 140/70, a heart rate of 125 bpm, a shallow respiratory rate of 35/min, and a
temperature of 38.9° C (102° F).
He demonstrated a strong, “barking” cough, and he produced a small amount of blood-streaked
sputum during each major coughing episode.
His skin appeared cyanotic. Over his right lower and middle lobes and his left lower lobe,
he demonstrated increased tactile and vocal fremitus, dull percussion notes, bronchial breath
sounds, and crackles. His SpO2 was 86%. His ABGs were as follows: pH 7.55, PaCO2 26 mm Hg,
HCO3– 24 mmol/L, and PaO2 53 mm Hg.
1. Is the pt in respiratory distress?
2. What evidence supports it?
3. What is the interpretation of the current blood gas? Why?
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Case Study
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4. Why is the sputum blood-streaked?
5. What are some immediate actions that he RCP could take?
6. What are treatment recommendations that the RCP could make?
7. If the patient’s condition, worsens what disease process could result?
The Next Day
The respiratory therapist assigned to evaluate the patient gathered the following clinical
information:
The patient stated that he slept most of the night and was breathing more easily.
The patient’s blood pressure was 135/85; his heart rate was 90 bpm; his respiratory rate was
19/min; and he had an oral temperature of 37.3° C (99° F).
He had a strong, nonproductive cough.
His morning chest X-ray and report indicated partial resolution of the pneumonic process
but persistent consolidation or atelectasis in the right lower and middle lobes and left lower lobe.
In these lung areas, the tactile and vocal fremitus had increased, and dull percussion notes and
bronchial breath sounds were audible. His SpO2 was 97%. His ABGs were as follows: pH 7.44,
PaCO2 35 mm Hg, HCO3– 24 mmol/L, and PaO2 163 mm Hg.
1. Is the pt in respiratory distress?
2. What evidence supports it?
3. What is the interpretation of the current blood gas? Why?
4. What do the findings on the chest x-ray indicate?
5. What are some immediate actions that he RCP could take?
6. What are treatment recommendations that the RCP could make?
REVIEW
1.
2.
3.
4.
5.
Sputum sample/induction (was/was not) indicated in this patient because
____________ .
Oxygen therapy (was/was not) indicated because ______________________ .
Bronchial hygiene therapy (was/was not) indicated because _________________
______________________ .
Aerosolized medication therapy (was/was not) indicated because ____________
______________________ .
Hyperinflation therapy (was/was not) indicated because _________________
_____ .
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