Mercader, Nicole Kirby NCM 112 RLE

BSN 3-A 08/07/2023

GROUP 3A CASE
Mr. Martin is a 55-year-old man who presents to his primary care provider (PCP) on a Tuesday with
complaints of a productive cough for 3 days with fever, chills, fatigue beginning in the last 24 hours. This
clinic has capabilities for x-ray, rapid lab tests, and simple IV infusions. His PCP hears coarse rhonchi in
Mr. Martin's lungs and decides to take a chest x-ray. The x-ray shows right lower lobe infiltrates. His rapid
flu swab is negative. Mr. Martin's vital signs were as follows: BP 122/73 mmHg HR 102 bpm, RR 26 bpm
Temp 38.6°C, SpO2 94% on room air Weight 105 kg. Mr. Martin is diagnosed with pneumonia and sent
home on Azithromycin. Two days later, on Thursday, Mr. Martin still has the cough, fever, chills, and
fatigue and is now having body aches on and off and is short of breath intermittently. He calls his PCP
concerned that the antibiotics are not working. His PCP agrees and changes his antibiotic to Amoxicillin.
On Friday, Mr. Martin's wife calls his PCP again because he is struggling to even get out of bed and is
very fatigued and feverish. She reports a fever of 102.9°F. The PCP tells him to come into the clinic. He
arrives at the clinic 20 minutes later

DATE AND TIME FOCUS DATA, ACTION, AND RESPONSE

08/08/2023 (Tuesday) Productive acute cough D: Client complains of having a productive

cough for 3 days already. Presence of
coarse rhonchi sounds in client’s lungs. ---

A: Client was sent home and prescribed

by the doctor to intake an antibiotic
(Azithromycin). Promote deep breathing
exercise and coughing technique.
Encourage client to intake more water or
fluid. Teach to the client the proper way of
taking the medication. --------------------------

R: Client verbalized understanding.---------

08/10/2023 Productive acute cough D: Client complains that he still has cough
(Thursday) and the antibiotics prescribed are not
working. --------------------------------------------

A: Client was sent home and the doctor

changed his prescription to another
antibiotic (Amoxicillin). Promote deep
breathing exercise and coughing
technique. Encourage client to intake
more water or fluid. Teach to the client the
proper way of taking the medication.--------

R: Client verbalized understanding. --------

 DATE AND TIME FOCUS DATA, ACTION, AND RESPONSE

08/08/2023 (Tuesday) Fatigue D: Client complains that he’s feeling fatigue

that began in the last 24 hours. The client’s
vital signs are BP = 122/73 mmHg, HR = 102
bpm, RR = 26 bpm, and Temp = 38.6°C. The
client weighs 105 kg. --------------------------------

A: Client was sent home and prescribed by

the doctor to intake an antibiotic
(Azithromycin). It is advised for him to take
rest and refrain from doing any strenuous
activity. ----------------------

R: Client verbalized understanding.--------------

08/10/2023 Fatigue D: Client complains that he still feels fatigued.

(Thursday)
A: Doctor changed his prescription to another
antibiotic (Amoxicillin). Promote complete bed
rest to the client It is advised for him to refrain
from doing any activity. -----------------------------

R: Client verbalized understanding.--------------

08/11/2023 (Friday) Fatigue D: Client’s wife called in and told that he is

very fatigued and is struggling to get out of
the bed.

A: Doctor told the patient to come to the

clinic. Prepare the bed and room for the
patient. -----

R: Will continue to monitor patient.---------------