Running head: CLINICAL CASE LOGS REPORT 1

Clinical Case Logs Report

Student’s Name

Institution
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Case description

This is a differential diagnosis case of an 89-year-old female patient suspected to be

suffering from either UTI, Influenza, Bronchitis, Pneumonia, or URI. The 89-year old patient has

been subjected to increased altered mental status for the last two days. The daughter reports that

the patient has had a productive cough for more than five days. The patient has a past medical

history of congestive heart failure, anxiety, hyperlipidemia, and Paget’s disease. She has been

under various medications for the last two days, as indicated in the case. The patient’s review of

systems suggests that she has been feeling more tired than usual and has had a fever, chills, and

general weakness (Thompson, 2018). She has also complained of various cardiovascular and

respiratory symptoms. The vital signs are BP 104/75, HR 82, and RR 18 Temp 98.7. The patient,

however, seems to have no physical assessment issues. A HEENT examination also came out

positive.

The results of the examination suggest the possibility of a diagnosis of Cough and Upper

Respiratory Infection as well as Urinary Tract Infection. Currently, the plan is for the patient to

increase her intake of fluids and undergo a chest x-ray, viral swab, urine analysis with culture,

and neurology consultation.

The choice of this case was based on the fact that it offers a challenge in diagnosing the

patient due to the numerous symptoms. The case provides an example of knowledge

enhancement in this field. Cases such as these are common during practice, and so proper

analysis of the same will be critical towards better performance during practice.

How diagnosis was carried out

The diagnosis was carried out using the necessary steps of diagnosis to arrive at all the

possible causes identified. The diagnosis was first carried out through initial diagnostic
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assessment. In this case, the focus was mainly on the patient’s medical history, evaluation of her

chief complaint and symptoms, initiating a physical exam, differential diagnosis formation, and

carrying out diagnosis tests. The next step involves diagnostic testing where her performance

was evaluated, results of the initial diagnosis assessment interpreted, and the results

communicated (Thompson, 2018). Lastly is the referral, consultation, treatment, and follow-up

step. In this case, a follow-up is done, reference and consultations were done. Where appropriate,

the patient is discharged as long as they comply.

Differential diagnosis mainly involves integrating all information gathered from the

initial diagnosis. This is a critical process because it relies heavily on all data collected. In case

there is insufficient information, the differential diagnosis may not be successful. In some cases,

any errors that may have happened during the initial diagnosis may negatively affect this process.

The differential diagnosis for these cases was made as follows:

1. Pneumonia differential diagnosis

Risk Factors

1. Age: The risk of CAP increases mainly with age with those above 65 years at higher risk.

2. Viral respiratory tract infection – the presence of viral respiratory tract infections is a risk

factor for primary viral pneumonia. It may also expose one to secondary bacterial

pneumonia. Influenza virus infection is another risk factor.

3. Impaired airway protection – a diagnosis of microaspiration for upper airways secretion

and microaspiration of stomach contents is a risk factor for pneumonia.

4. Smoking and alcohol overuse – abuse of smoking and alcohol are also risk factors for

CAP.

5. Other lifestyle factors – CAP is associated with other lifestyle risk factors such as low-
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income residence settings, exposure to environmental pollutants, and living in crowded

places (Thompson, 2018).

2. Influenza differential diagnosis

Risk factors

 Age (above 65 years more susceptible)

 Underlying medical conditions

 Sore throat, dysphagia

 Shortness of breath and chest pains

 Nausea, diarrhea, and vomiting.

 Headache, myalgia (Thompson, 2018).

3. Acute bronchitis differential diagnosis

Age factors

 Viral infections like flu and cold are risk factors

 Bacterial infections also risk factors

 Presence of asthma or allergies

 Smoking

 Pneumonia (Thompson, 2018).

4. UTI differential diagnosis

Risk factors

 Fever

 Urinary frequency/dysuria

 Instrumentation (indwelling urinary catheters)

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 Kidney Stones

 Chills

 Clinical Manifestations:

 Female sexual trauma

 Flank/groin pain

 Malaise (Thompson, 2018).

5. URI differential diagnosis

Risk factors

 Allergic Rhinitis

 Pediatric Retropharyngeal Abscess

 Infectious Mononucleosis

 Reflux Laryngitis

 Community-Acquired Pneumonia

 Tuberculosis

 Asthma

 Obstructive Sleep Apnea

 Otitis Media

 Immunoglobulin A Deficiency

The treatment plan for the patient

 Increase fluids: the advice to increase fluid intake was done mainly because she is

suspected to be suffering from acute respiratory infections. The major benefit of

increased fluid intake for the lady would be to replace lost fluids since her condition leads
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to a high rate of fluid loss. Her increased breathing rate and dehydration are some of the

reasons she should keep rehydrated through the increased fluid intake. The high fluid

intake will also help reduce the viscosity of mucus, making it easier for her to discrete the

mucus. The water will also be a remedy for most of her signs and symptoms, such as

cough. The fluids are likely to soothe her throat, thereby reducing the pain and discomfort

associated with a sore throat. Warm fluids are also recommended to help break down the

mucus.

 Do a viral swab: from the patient’s symptoms, she may be suffering from a viral

infection. The best way to determine a viral infection is to always do a viral swab.

Performing a viral swab is likely to help the physician identify the specific viral infection

she may be having. Performing a viral swab on her is also critical to help determine

whether she is suffering only from a bacterial infection or if she also has a viral infection.

The results of the viral swab are also likely to guide the physician to order further tests on

the lady.

 Chest x-ray: a chest x-ray is very critical when it comes to clear identification of what

may be wrong with a patient’s upper chest. It gives a clear picture of the patient’s lungs,

heart, airways, bones, blood vessels, and chest wall. In this case, the chest x-ray will help

the physician to diagnose various symptoms, including shortness of breath, fever, chest

pain, injuries, cough, or any other condition. The results of the x-ray can also be used to

monitor past treatment on various conditions that the patient may have undertaken before.

It also helps determine the extent of some conditions that may be facing the lady, such as

bronchitis or pneumonia.

 Urinalysis with culture: this test is mainly performed on older adults’ urine to examine
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if they have any bacterial infection in their urinary tract. The urinalysis with culture helps

identify some bacteria which may not be visible through normal urinalysis procedures.

 Increased altered mental status and lethargy: altered mental status and lethargy are

critical, especially in older patients, to determine any acute mental changes. This test is

critical to determine any cases of acute brain dysfunction, which may have been

precipitated by an underlying medical illness. In most cases, the underlying medical

illnesses may be life-threatening if not addressed on time. They may cause stupor and

sometimes coma. In this case, an increased altered mental status and lethargy test is

critical to determining the patient’s underlying etiology.

 Follow up after two to three days: follow-up is critical to confirm whether a patient is

strictly following a treatment plan. The physician can carefully monitor the patient during

follow-up to determine whether they are responding well to medication. Physicians can

easily diagnose the patient if they are not responding well to treatment or if they show

new signs of another condition. In case of non-response to medication, the physician may

opt to try out a new treatment plan or enhance the current plan by increasing or reducing

medication (Yamada et al., 2018).

NONPF Competencies

 Scientific foundations competency: The first competency that was addressed in this

clinical experience is the scientific foundations' competency. The clinical experience was

mainly based on scientific data, which was properly analyzed to improve nursing

practice. The patient data sets were effectively compared with evidence-based standards

to improve the quality of care.

 Quality competency: the clinical case also shows the application of quality competency-
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based on the quality of care that was provided. The case shows reliance on available

evidence to improve quality. The case also shows the use of skill in peer review to

establish a culture of excellence. The case also allows for personal improvement of

quality through learning.

 Practice inquiry competency: this case mainly offers an opportunity for the application of

nursing knowledge into practice. It allows one to effectively study and learn this case

which can easily be applied in a care setting. It also applies clinical investigative skills,

which are necessary during practice.

 Technology and information literacy competency: this case mainly involved the

application of technology and literacy to help perform a proper diagnosis. It involves

technical knowledge and the ability to translate that technical knowledge into nursing

knowledge.

 Health delivery system competency: this clinical case also allows one to apply

organizational practices knowledge to enhance the delivery of health care. The case also

offers an opportunity for one to apply broad-based skills learned in class and interstate

into practice (American Association of Colleges of Nursing, 2016).

QSEN Competencies

 Quality competency: this clinical case offers an opportunity for one to gain skills to

improve their quality efforts. It helps one learn how to measure any changes and improve

their quality of care. Quality care provision is very critical in ensuring positive patient

outcomes. This case is an example of how a practitioner can apply their knowledge to

improve quality provision.

 Safety competencies: this case also indicates more focus on the safety of the patient,
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which is critical in developing safety competencies during practice. It enables one to

apply existing resources to enhance the quality of practice. Safety is very critical to

ensuring positive patient outcomes. In this case, a focus on safety must be paramount to

ensure proper diagnosis and successful treatment process.

 Teamwork and collaboration: this case encourages teamwork between colleagues by

enhancing personal attributes, which increase their strength and encourage awareness.

One can effectively work within their scope of practice by working together with every

member of the health care team. Working together is one of the most critical ways to

improve the quality of care in a nursing care setting.

 Patient-centered care: this clinical case is a perfect example of patient-centered care,

which allows one to apply the knowledge they have acquired in class in practical

situations. It enhances various skills such as listening skills, clinical diagnosis skills, and

care plan implementation, among others.

 Evidence-based practice: this case allows the demonstration of knowledge of various

health research methods and processes. It encourages the application of various skills,

which include health research skills, data application skills, and application of clinical

expertise. The evidence-based practice mainly encourages practitioners to apply nursing

and clinical research into practice (American Association of Colleges of Nursing, 2012).

Patient diagnosis plan

Nursing diagnosis Outcomes and evaluation Interventions

 Five possible diseases  Based on the exam of The plan for the patient is to

have been identified the patient a possible increase fluids, do a viral

which includes UTI, diagnosis of Cough swab, chest x-ray, urine

Influenza, Bronchitis, and Upper analysis with culture and

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Pneumonia, URI. Respiratory Infection Neurology consult for

is possible along with increased altered mental

Urinary Tract status and lethargy. Follow up

Infection. scheduled in 2-3 days

Evidence used in this case

1. Signs

The signs part of this plan was included to give a general view of the physical response by the

patient based on a medical fact. The symptoms are critical towards understanding the case

affecting the patient, including all vital facts about the patient. In this case, the patient’s short

history has been provided, which helps in determining the signs they may be facing.

2. Past medical history

Past medical history are always critical when making patient diagnosis. That is because in most

cases, past medical history is always indicative of present medical condition. Patient medical

history is critical during diagnosis because it helps the physician to determine which type of tests

the patient will undertake. In most cases, patient signs and symptoms may not be sufficient

evidence to determine an underlying condition. The best way to analyze such a condition would

be to look at PMH to determine whether any past condition may be related to current symptoms.

In this case, the patient’s past medical history has been identified so that the information can be

during differential diagnosis. Some of the patient’s past conditions may have a role to play in her

current condition. The information is also useful in helping the physician to determine how to

address her current conditions.

3. Medications

The list of medications are critical in this medical report because they give an indication of the
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intervention methods that have been applied on the patient. Any physician taking over this case

will have better knowledge of what has been done to the patient so they can analyze whether it

has proven successful or not. The information also helps the physician to come up with new

medication in case the prescribed medication fails to tackle the symptoms. In this case, the

medications the patient has taken has been identified which can help the physician to determine

whether they have proven successful or not.

4. NKDA

Incidents involving drug allergies usually occur in cases where no records were made early

enough about a patient’s allergies. Drug allergy cases are always severe and may sometime

become fatal if not addressed on time. The best way to avoid such accidents, therefore, would be

to accurately record any allergies that a patient may have before being subjected to medication.

The patient has indicated that she has no allergies to any known medication, which makes her

case easier to address.

5. PSH

Determining the past social history of a patient is critical towards the proper analysis of disease.

For example, recent history with drinking, smoking, or other drugs is used to help physicians link

a condition to specific precursors that may have been linked to them. In this case, the patient has

no past drug or smoking use, which is critical when addressing her.

6. ROH

The review of systems is used mainly used on patients who fall under various risk categories.

The ROH is primarily used to specifically focus on individual risk factors by asking specific

questions that may lead the physician to the risk categories. In this case, general questions were

asked to determine whether the patient had certain types of signs and symptoms. The next line of
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questioning was focused on identifying whether the patient had respiratory symptoms. Lastly, the

focus was on cardiovascular disease symptoms.

7. Vital signs

Every diagnosis process must always determine various vital signs which determines whether the

patient is under more stress or not. In this case, the physician tested mainly BP, HR, RR, and

temperature.

8. Physical assessment

Subjecting the patient to further physical tests is also critical to determine the level of stress they

may be under. Any underlying pain or symptom is covered during the HEENT examination. The

patient, in this case, underwent a full HEENT test to determine if there were any underlying

symptoms. Other forms of physical examination were done in the way of respiratory examination

and cardiovascular examination.

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References

American Association of Colleges of Nursing. (2012). Graduate-level QSEN competencies:

Knowledge, skills and attitudes. Washington: American Association of Colleges of

Nursing.

American Association of Colleges of Nursing. (2016). Adult-gerontology acute care and primary

care NP competencies.

Thompson, M. S. (2018). Clinical Signs Approach to Differential Diagnosis. Small Animal

Medical Differential Diagnosis, 1.

Yamada, T., Takayanagi, T., Fujimoto, R., Fujitaka, S., & Nomura, T. (2018). U.S. Patent

Application No. 15/821,889.

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