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Name

Institution affiliation

Course

Professor

Date
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Patient Information

Patient Initials: CL Patient Encounter: Initial Visit

Date: 12/16/2020 Age: 56

Sex: Male Race: White

SUBJECTIVE

CC: High fever and productive sputum.

HPI: Mr. Calvin Lewis is 56-year old with fever and productive sputum, which has lasted for

three days. The symptoms have increasingly worsened. He denies palpitations, SOB, DOE, or

headache. However, he reports chest pains on the right side when taking a breath. His appetite is

low, but he drinks fluids. He denies vomiting, nausea, diarrhoea, or abdominal pain.

Current Medications: Metoprolol and Celecoxib.

PMH: Currently, he has no medication for any antibiotics for several years. PMH is essential for

hypertension and arthritis. He also had a vaccination for influenza this year.

Chronic Illnesses: Hypertension and arthritis.

Immunizations Hx: Influenza immunization 7/2020.

Family History: The parents of the patient had diabetes and hypertension, while one of the

siblings have an asthma condition.

Social History: Mr Lewis is 56 years old and a banker. He lives with his family in an estate near

the hospital. He smokes a packet of cigarettes daily.

ROS

General: The patient has decreased appetite, fever, and productive sputum.

Cardiovascular: He denies palpitations but complains of chest pain.

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Skin: The patient has a standard colour, moisture, warm and sweat. He denies skin itching,

unusual hair growth, and lump.

Respiratory: He produces sputum, has increased tactile fremitus, dullness of percussion and

decreased breath sound. The patient denies SOB, DOE, and has no history of lung diseases.

Eyes: The patient complains of reduced vision and soreness. However, there is no redness or

swelling nor discharge.

Gastrointestinal: He denies diarrhoea, vomiting, nausea, or abdominal pains.

Ears: The patient has no hearing aid and reports no changes in hearing. There is no tinnitus,

discharges or infection.

Genitourinary: Genitourinary is normal. There was no blood in urine and no change in the urine

colour. He had no urinary urgency.

Nose/Mouse/Throat: He had a runny nose with no itching, nosebleeds, no change of smell or

sinus pain. He coughs up coloured mucus. He had no bleeding gums, teeth and mouth had no

pain, no excessive salivation or altered taste. The tonsil size, colour, and position was usual and

had no sore throat.

Musculoskeletal: The patient has a history of arthritis, joint stiffness, fatigue, pain, and limited

movements.

Breast: The patient denies rash, pain, tenderness, or skin changes.

Hematologic: Has no anaemia, bleeding or bruising.

Allergies: No history of asthma, eczema, hives, or rhinitis.

Neurological: The patient referred to fatigue. He denied memory disorder, seizures, and mood

change. He reported no hallucinations, tremors or numbness.

Lymphatic: The patient-reported pain, discomfort and tenderness.

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Psychiatric: He suffers from depression and loss of memory but reports no history of mental

illness.

OBJECTIVE

Weight: 95 BMI: 34

Temp:38.5 BP: 128/86

Height: 5’6 Pulse: 101

RR: 18

Physical Examination

General Appearance: A male of 56-year-old. He is overweight and well dressed. He appears

distressed and uncomfortable during the examination. The patient doesn’t maintain an upright

posture and complains of pain in the upper right robe. The patient speaks clearly and answers all

questions asked.

Skin: has good turgor, warm, and dry with no rashes.

HEENT: No sinus tenderness, no lymphadenopathy. TMS has no discharge. There are no

cobblestoning in pharynx, exudate, or enlargement. The neck has no thyroid enlargement. The

trachea has no alterations. Eyes have normal movement and no hearing losses.

Cardiovascular: Regular heart rate without murmurs, rubs or gallops. Peripheral pulses present.

Respiratory: Decreased breath sounds, increased tactile fremitus at the right lower lobe. Mild

crackles without wheezes.

Gastrointestinal: The abdomen is soft, no tenderness, bowel sounds present, and no

organomegaly.

Breast: During the pulse, there were no physical lumps or bumps and no deep discharge. There

was no axillary adenopathy or tenderness.

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Musculoskeletal: The hips, knees, and ankles normal with joint stiffness and tenderness.

Neurological: There are no sensory perception disorders; speech is normal and complains of

fatigue only.

Psychiatric: He looks depressed with anxiety. The patient reports no suicidal thoughts and has

no history of mental impairment.

Lab Tests: 523533 General Lab Panel

Special Tests: Chest x-ray, Blood Test, Sputum test.

ASSESSMENT

Primary Diagnosis- Community-Acquired Pneumonia

Community-acquired pneumonia is an infection of the lower respiratory tract caused by

Streptococcus pneumonia, Moraxella catarrhalis, and Haemophilus influenzae (Thanavara,

2017). The symptoms vary from mild to severe, including chest pain when breathing or

coughing, sputum production, confusion for old age, fatigue, and shortness of breath.

Differential Diagnoses.

1. Pulmonary aspiration

Pulmonary aspiration is a condition where there is a presence of ailing secretions or matter into

the trachea and lungs. This technique is commonly used for infection detection (García-Elorriaga

& Del Rey-Pineda, 2016). It usually used in setting where there is a need for careful monitoring

capacities, and management of complications is required. When making the diagnosis of

aspiration pneumonia, the following points should be considered: the risk factor of aspiration; if

the chest radiographs show primary lesions in the upper lobe or lower lobe (Cao et al., 2017).

Aspiration pneumonia is caused by gram-positive bacteria or Streptococcus aureus.

2. Pulmonary embolism
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Where radiographs show infiltrate, it is crucial to consider noninfectious causes such as

pulmonary embolism (Thanavara, 2017).

3. Viral bronchitis

Distinguishing viral bronchitis from CAP is essential for antibiotics stewardship. Chest

radiographs distinguish an alveolar infiltrate on CAP patients’ chest from normal chest

radiographs for patients with bronchitis (Rider & Frazee, 2018; Cao et al., 2017).

PLAN

The 57-year patient with history as indicated above;

The CURB-65 score shows that he can be treated in an outpatient setting.

Laboratory/Diagnostic Test Ordered:

The laboratory tests ordered by Harnett (2017) are chest x-ray, blood cultures test, and CBC.

Pharmacologic treatment:

Azithromycin 500mg x 3days. Use antibiotics therapy until recovery: mezlocillin sodium,

oseltamivir, and Linezolid. (Xia et al., 2020). Use acetaminophen, ibuprofen for fever and pain.

A pneumococcal vaccine is administered today.

Teaching/Education:

Avoid smoking and excessive alcohol drinking (Cao et al., 2017). Drink fluid regularly. Cough

hourly and take deep breaths. Use a humidifier to make the air moist and warm.

Follow-up:

Repeat Chest x-ray after six months to verify pneumonia was not triggered by underlying mass.

Lessons Learned and its Effectiveness in Nursing Practice

The soap analysis for this CAP helps understand the pathogenesis and apply immunology

knowledge of infectious disease, which cannot be clearly understood. Moreover, CURB-65

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criteria help in clinical decisions relating to admission, depending on the pneumonia severity

score (Cao et al., 2017). The severity index for patients with CAP help identifies candidate for

outpatient versus inpatient treatment.

This lesson significantly affects my nursing practice in the future when follow up is made by the

patient. The understanding of pathogenesis helps in the evaluation of immune response for the

patient with CAP and focus on more diagnostic strategies.

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References

Cao, Bin & Huang, Yi & She, Dan-Yang & Cheng, Qi-Jian & Hong, Fan & Tian, Xin-Lun &

Xu, Jin-Fu & Zhang, Jing & Chen, Yu & Shen, Ning & Wang, Hui & Jiang, Mei &

Zhang, Xiang-Yan & Shi, Yi & He, Bei & He, Li-Xian & Liu, Ning & Qu, Jie-Ming.

(2017). Diagnosis and treatment of community-acquired pneumonia in adults: 2016

clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical

Association: 2016 China CAP Guideline for Adults. The Clinical Respiratory Journal.

DOI: 12. 10.1111/crj.12674.

García-Elorriaga, G., & Del Rey-Pineda, G. (2016). Basic Concepts on Community-Acquired

Bacterial Pneumonia in Pediatrics. Pediatric-infectious-disease.imedpub.com.

https://pediatric-infectious-disease.imedpub.com/basic-concepts-on-communityacquired-

bacterial-pneumonia-in-pediatrics.pdf. Accessed 16th December 2020.

Harnett, G. (2017). Treatment of Community-Acquired Pneumonia: A Case Report and Current

Treatment Dilemmas. Case Reports in Emergency Medicine, 2017, 1-7. doi:

10.1155/2017/5045087

Rider, A., & Frazee, B. (2018). Community-Acquired Pneumonia. Emed.theclinics.com.

https://www.emed.theclinics.com/article/S0733-8627(18)30066-X/pdf. Accessed, 16th

December 2020.

Thanavara, J. (2017). Common Respiratory Disorders in Primary care. Clinical decision making

for adult-gerontology primary care nurse practitioners. Jones & Bartlett Learning, LLC.

samples.jbpub.com.

http://samples.jbpub.com/9781284065800/Chapter3_Sample_thanavaro.pdf. Accessed,

16th December 2020.

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Xia, H., Gao, J., Xiu, M., & Li, D. (2020). Community-acquired pneumonia caused by

methicillin-resistant Staphylococcus aureus in a Chinese adult. A case report.

Medicine, 99(26), e20914. doi: 10.1097/md.0000000000020914. Accessed, 16th

December 2020.