CASE STUDY
3-15-13
By: Brandy Schnacker
Patient:
66 year old, Native American Female
Past Medical History
Illnesses
PSVT, Osteoarthritis, Migraine, GERD, Asthma, Hypoglycemia, Smoker, Rhinitis,
Neck Pain, RLS, CAD, DJD Neck, SAR, Radicular Neck Pain, Hyperlipidemia, PVD,
HTN, Contact Dermatitis, and Depression
Injuries
None Noted
Surgeries
Total Hysterectomy – 1-1-1988
BSO – 1-1-1988
Bone Graft – 1972
Reproductive History
6 Total Pregnancies
6 Full Term Deliveries
6 Living Children
No miscarriages or abortions
Last Period 1988
Immunizations
Tdap – 2-29-12
Pneumonia – 8-27-12
H1N1 – 12-18-09
Last Flu Shot – 10-19-10
Social History
Smoker ½ PPD for 50 years
Native American Culture
Lives with her daughter who helps take care of her.
Family History
Maternal Grandfather – Died from a stroke
Mother – Died from natural causes (old age)
Father – HTN, CAD – Died
Chief Complaint
Temps of 101 for the last four days, nausea, SOB, sore throat, productive cough,
chills, body aches, has not been able to eat anything, only is drinking water.
History of Presenting Illness
4 days of fevers as high as 101
Cough with brown, thick sputum
Can not lay flat to sleep, has to sleep up on pillows or in the recliner
Using Nebulizer every 2 hours over the last four days
Increased oxygen at night to 3L
Nausea
Body Aches
Sore Throat
Still smokes cigarettes
Exposed to strep throat
Did not receive immunization for flu this season
Review of Symptoms
HEENT – Sore throat – hurts to swallow. No headaches, ear pain or drainage.
Some clear drainage from nose, no sinus pain. Eyes – No complaints.
Psychiatric – Does feel fatigued, sleep pattern has been difficult with her
breathing. Can only sleep about 2-3 hours at a time.
Neurological – No complaints
Musculoskeletal – Body aches, no pain, swelling, ROM
Cardiovascular – No complaints of chest pain, numbness, tingling,
lightheadedness, or dizziness.
Respiratory – Complaints of SOB, cough with brown, thick sputum. Dyspnea
with exertion and rest. Hard to catch her breath. Have noticed wheezes when she
breaths. Cannot lay flat to sleep. Had to increase use of oxygen to 3L at night time.
Skin – Intact with a slow turgor response.
GI – Nausea when eating foods. Only been drinking water because food makes
her nauseated. No vomiting, cramping, bloating or diarrhea.
GU – No complaints
Reproductive – No complaints
Endocrine – No complaints
Breasts – No complaints
Peripheral Vascular – No complaints
Hematologic – No complaints
Constitutional – Very ill appearing, moderate distress when breathing, no
appetite.
Physical Findings
Constitutional - 135lb, 103.2 temperature, respirations – 24, pulse – 92, blood
pressure – 118/68, no complaints of pain, 90% on room air.
Cardiac – S1, S2 regular, No murmurs, rubs or clicks
Respiratory – Dyspnea upon exertion and rest. Lungs decreased bilaterally
throughout all lobes with slight expiratory wheezing in lower lobes.
Skin – poor turgor elasticity, eyes sunken within her face.
HEENT – PERRLA, TM gray and pearly, Nose and nasal mucosa with erythema,
no swelling, Pharynx with erythema, no swelling or exudates. No sinus tenderness or
lymph edema.
GI – Nontender, BSX4, active
Psychiatric – A/O X 4, in moderate distress.
X-ray of the chest, CBC and Comprehensive Chemistry could have been done at
this facility but it would have taken quite some time for the results to come back so held
off on doing these tests for the hospital to order.
Differential Diagnoses
Fever Unspecified – Primary Diagnosis – She had been having fevers for four
days and there were not x-rays done or lab work at the time so we could not diagnosis
her with pneumonia or other diagnosis.
Dehydration – Secondary Diagnosis – Skin turgor elasticity was slow and eyes
were sunken in.
Bronchitis – This could have been her main diagnosis but needed to run a CBC
to see about infection but was going to have her go to the hospital to have her lab work
done there.
Pneumonia – Could not be ruled out but needed to have a chest x-ray done and
was going to have the hospital do that after admission.
Influenza A/B – Could not be ruled out at this time because needed to do a swab.
Also patient had not had her flu shot for this season.
Exacerbation COPD – With her long history of smoking this could be a diagnosis
but you usually do not see an exacerbation with a run of fevers.
Plan of Care
99213
Admit to Stormont Vail Hospital
Hospitalist to Admit Patient
Patient’s daughter was with her through the whole appointment. Both the patient
and her daughter were kept abreast of what was going on throughout the appointment.
Discussed with the daughter if she was willing to take her mom to the hospital or if they
would like to go by ambulance. Discussed with the patient if she was willing to go to the
hospital to get rehydrated and also find the cause for her fevers. Pt and daughter were
both in agreement with plan of action. Also explained the process of admission to
Stormont Vail to patient and daughter. Patient and family both in agreement to
hospitalization and how to transport patient to hospital via private car.
Reflection on Care Provided
I believe that throughout this appointment I was able to see the distress the
patient was in and came up with a quick plan of care to help her get the best relief
possible. I was able to give report to the hospitalist so that he understood why the
patient needed hospitalization. I believe that I handled myself in a professional manner
when talking to the accepting hospitalist and was able to give him the appropriate
information that he needed to assess the situation. I believe the next time that I have a
patient to be admitted that I am better skilled at knowing what type of information they
are looking for and any procedures we have done for the patient. We did not do any lab
work or x-rays because they were going to do that at the hospital and it would have
taken our facility longer to produce the reports and I did not want her sitting in the office
being uncomfortable while we waited for results. It was more important to get her on
the road to the hospital so that she could start her care immediately and also to feel
better. I believe that I would like to have been a little faster on writing my note so I could
have gotten her gone a little faster, but I wanted to make sure that there were no
important information left out for the receiving facility and physician. Evidence does
show that fever is the first sign of sepsis and systemic inflammatory response syndrome
which can be fatal at times. The recommendations for fever for possible pulmonary
infections include a chest imaging study, respiratory secretions to test for microbiology,
lab work consisting of blood cultures, and CBC (Kramer, 2010). Having this patient get
to the hospital for the appropriate care will assist her in the appropriate treatment for her
illness.
REFERENCES
Kramer, R. M. (2010). Evidence-Based Practice Fever Evaluation and Early Recognition
of Systemic Inflammatory Response Syndrome in Critical Care Patients.
Dimensions of Critical Care Nursing, Vol. 29, No. 1, 20-28.