Running Head: CLINICAL CASE STUDY
Clinical Case Study
History and Physical Signs & Symptoms
S.S. is a 57 year old Caucasian male on the ICU floor, who was admitted to the hospital with a diagnosis of pneumonia. After culture, the cause of the pneumonia was found to be coccidioidomycosis (Valley Fever). The patient showed presenting symptoms of a respiratory distress (SPO2 of 89%), fever (102.4°F), weight loss, productive cough, dyspnea, crackles and wheezing in lungs, pleural effusion, and malaise. S.S. has several co-morbid factors affecting his recovery: COPD, Diabetes Mellitus Type II, hypertension, chronic renal insufficiency, depression, and history of benign prostatic hyperplasia (BPH). The patient had a transurethral resection of the prostate (TURP) two years to treat the BPH. Recent surgical history includes the placement of a tracheostomy, a PICC line, and a chest tube since admitted to the hospital. Systems Review
S.S. was oriented to person, place, and time. His communication was non-verbal due to tracheostomy placement, but used paper and pencil to communicate as needed. Pupils showed PERRLA. The patient showed muscle tone and strength within normal limits in all extremities. The patient was on a mechanical ventilator set at an FIO2 of 60 and an oxygenation saturation reading of 97%. His cough was productive with thick yellow sputum. He had dyspnea and tachypnea, with a respiratoy rate ranging from 22 to 27 breathes per minute. A right chest tube in was draining on gravity with no signs of malfunction or infection. There were decreased breath sounds in the lower lobes bilaterally with coarse crackles. The patient received a chest x-ray upon admission noting opacities throughout the lungs showing pneumonia. His most recent chest X-ray exhibits improvement in the lung fields with the lack of a pneumothorax. Capillary refill was less than two seconds with palpable peripheral pulses in all four extremities. The patient’s heart rate ranged between 89 beats per minute to 125 beats per minute, with the apical pulse having a arrhythmia, showing atrial fibrillation. The patient’s current EKG presented atrial fibrillation with rapid ventricular response. This is the first time the patient has shown signs of atrial fibrillation. Oral mucosa was dry and pale with white patches along his tongue and lips. His abdomen was soft and non-tender with active bowel sounds in all four quadrants. There was a Foley catheter inserted with a consistent output of more than 30 ml per hour of yellow urine. He was receiving continuous feeding through a nasogastric tube with residual less than 100 ml. The patient also had a Flexi-seal inserted to protect skin integrity. The most recent abdomen X-ray demonstrates no evidence of pneumoperitoneum with continued bilateral basal pneumonia. The patient’s skin color was pale with signs of 2+ pitting edema along posterior trunk. There were areas of torn skin and ecchymosis on forearms bilaterally from tape removal and reddened, dry skin around the surgical incision for his tracheostomy. None of the wounds had any remarkable drainage. The PICC line had a patent triple lumen with no signs of infection or pain present. The patient complained of 7 out of 10 crushing pain in his chest. He also communicated that he had pain in his mouth due to dryness from his NPO status and tracheostomy. For a list of the patient’s laboratory values and interpretation (Kee, 2005) and current medications (Wilson, Shannon, & Shields, 2009), see the attached paperwork. Pathophysiology
The patient’s presenting problem was pneumonia, which was caused by the inhalation of microorganisms in the air. Once the microorganism gets past the upper airway defense, it can overtake the alveolar macrophage resulting in an activation of the body’s defense mechanism, including the release of inflammatory mediators, cellular infiltration, and immune activation. This response damages bronchial mucous and...
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