Exam (elaborations)
NUR 6111 Adv Nursing Practice 1 Module 3 Respiratory Case study_2
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- William Paterson University
NUR 6111 Adv Nursing Practice 1
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Module 3 Respiratory – Discussion Board Case StudyPresent illness. A 35-year-old male resident of Wayne, NJ presents with fever and cough. He
was well until 3 days earlier, when he suffered the onset of nasal stuffiness, mild sore throat, and
a cough productive of small amounts of clear sputum. Today, he decided to seek physician
assistance because of an increase in temperature to 38.3°C and spasms of coughing that produce
purulent secretions. On one occasion, he noted a few flecks of bright-red blood in his sputum.
Other pertinent history. It is March. He lives in a home in the city with his wife and 3 children,
aged 7, 9, and 11 years. The children are fully immunized. The 11-year-old child is recovering
from a “nagging” cough that has persisted for 10–14 days.
The family has a pet parakeet who is 5 years old and appears to be well. The patient has not
traveled outside the city in the past year. He is an office manager.
The patient smokes 1 pack/day and has done so since the age of 15 years. Several times a month,
especially during the winter, on arising from sleep, he produces ∼1 tablespoon of purulent
sputum.
Medical history. The patient has no history of familial illness, hospitalizations, or trauma. There
are no drug allergies or intolerance. The only medication he takes is acetaminophen occasionally,
for headaches. He drinks beer or wine in moderation.
Physical examination. His body temperature is 38.9°C (100°F), his pulse is 110 beats/min and
regular, and his respiratory rate is 18 breaths/min. His oxygen saturation is 93% while breathing
room air. There is mild erythema of the mucosa of the nose and posterior oropharynx. Inspiratory
“rales” are heard at the right lung base.
Laboratory and radiographic findings. His hemoglobin level is 12.5 g/dL, with a hematocrit of
36%. His WBC count is 13,500 cells/µL, with 82% polymorphonuclear cells, 11% band forms,
and 7% lymphocytes. His platelet count is 180,000 cells/µL. The results of a CMP screen are
unremarkable.
Chest radiography documents bilateral lower lobe infiltrates that are more pronounced on the
right side. There are no pleural effusions.
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, ACTIVITIES
1. Read the Case Study.
2. Compose an evidence-based response to the following items. Use APA format.
What other information is important at this type of visit?
What is your plan of care for this patient?
What tests or diagnostic would you consider today? Why?
Would you prescribe any medications? Discuss.
Would you make any referrals? To whom?
What counseling would you offer J.L. today?
3. Please justify your response with at least 2 peer-reviewed articles, journal resources, or
EBP resources (other than your textbooks).
4. By Wednesday of this week post your response.
By Sunday of this week, read and respond to at least 2 of your classmates’ responses. Do you
agree or disagree with their POC? Offer feedback, support your conclusion with a reference you
found.
As an APN it is important to obtain all pertinent information regarding history and
physical when interacting with a patient. In the case of this patient, it is important to gather
further information about the patient’s symptoms related to his respiratory infection. To begin,
further information should be gathered in regard to shortness of breath or chest pain. Shortness of
breath and chest pain can be signs of life-threatening infection or illness. If that patient was to
report chest pain, a cardiac work up would be indicated even if the leading differential diagnosis
is a respiratory infection. Additional pertinent information needed to adequately treat this patient
would be medication history regarding any recent antibiotic use as well as any care he received
in regard to these complaints previously. If the patient was recently prescribed antibiotics it
would alter the course of treatment as would previous care for the same complaints the patient
seeks care for on this visit.
As an APN, my working diagnosis would be community acquired pneumonia. Using this
working diagnosis my plan of care would begin with an assessment of the patient’s risk of 30-
This study source was downloaded by 100000881663784 from CourseHero.com on 08-17-2024 09:54:36 GMT -05:00
https://www.coursehero.com/file/143572330/Module-3-Respiratory-Case-study2docx/
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