XYZ Family Practice
The patient Amanda Smith aged 69 years old presented with continuous cough (five days long) accompanied by froth sputum and substernal pain, shortness of breath, fever up to 101F, decreased appetite, tachycardia up to 110 bpm, tachypnea up to 30 breaths per min, as well as slightly elevated blood pressure (135/92 mmHg). On examination, the woman experienced mild respiratory distress (tripod position was noted), and edema on legs was seen. The presumable diagnoses are supposed to be community acquired pneumonia (CAP), acute bronchitis (AB), congestive heart failure (CHF), and influenza. Further investigations include chest radiography, ECG, bronchoscopy, spirometry, sputum cytology, sputum Gram staining, serological tests, and polymerase chain reaction. In accordance with results of the laboratory and instrumental studies, the final diagnosis could be made, and appropriate treatment could be prescribed. The preliminary medical care for this patient should be directed to respiratory distress elimination.
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A 69-year-old female patient has come to seek medical care due to the following complains. The patient started coughing five days ago intermittently, but two days ago, the cough became constant, hence keeping her awake at night and accompanied by froth sputum and substernal pain. During physical examination, the woman experienced mild respiratory distress and adopted the position as for labored breathing. Swelling of the region between feet and ankles was noted. The patient had her blood pressure measured, and it was observed to be elevated (135/92 mmHg). The patient used to smoke one pack of cigarettes a day during 15 years but quitted to smoke five years ago.
The most likely diagnosis for this patient is supposed to be community acquired pneumonia (CAP) according to the following clinical data gathered: complaints for continuous cough that became productive, chest pain when coughing, high fever, shortness of breath, as well as tachypnea. However, the breath sounds on auscultation were normal without any pathological signs commonly seen in patients with pneumonia.
The differential diagnosis should be conducted with such pathological conditions as acute bronchitis (AB), congestive heart failure (CHF), and influenza (Wunderink & Waterer, 2014). AB could be suspected due to such clinical symptoms as continuous cough and shortness of breath. What is more, the patient stated that she used to be an active smoker. However, high fever is not typical for acute bronchitis. The latter is commonly associated with much sputum production, sore throat, as well as characteristic features of breathing on auscultation. Congestive heart failure could also be supposed due to the following data. The patient has been suffering for hypertension for more than four years. During the visit, the patient’s blood pressure was a little high. Swelling of lower extremities was noted. The woman experienced shortness of breath, tachycardia, tachypnea, as well as substernal pain – signs typically seen in patients with CHF (as manifestations of venous congestion). However, the signs of intoxication, such as high fever and decreased appetite, are not common for congestive heart failure. The differential diagnosis with influenza is primarily based on such clinical symptoms as cough, high fever, tachycardia, as well as tachypnea. Apart from that, the patient is known to be vaccinated against influenza nine months ago. However, the woman did not experience typical signs of a viral infection, such as sore throat, myalgia, nasal discharge, as well as red and watery eyes.
In order to determine the final diagnosis, the patient should be hospitalized for further investigation. A number of laboratory and instrumental studies should be conducted, including chest radiography, ECG, bronchoscopy, spirometry, sputum cytology, sputum Gram staining, and serological tests. The priority should be given to the chest X-ray, which may be helpful to diagnose either pneumonia (apparent lobar or bilateral infiltrates) or congestive heart failure (bilateral equal shadows above lungs). Moreover, ECG should be done in order to prove or exclude heart failure. Bronchoscopy could be useful in case of acute bronchitis in order to determine a chronic inflammatory process of the respiratory tract or significant bronchospasm commonly experienced by patients with acute or chronic bronchitis. Spirometry should be performed in order to measure the level of respiratory insufficiency. Sputum cytology as well as sputum Gram staining may be helpful when choosing the most effective antibiotic drug in case of infectious disease. Influenza test and other serological tests should be made in order to determine resistance of the body to viral and bacterial infections. Blood culture could show bacterial superinfection. Laboratory tests, including procalcitonin level determination, usually indicate either bacterial or viral infection. If CAP is proved by the X-ray study, the exact causing agent could be determined with the use of polymerase chain reaction. Such a diagnostic tool is a rather specific, sensitive, as well as quick method of detecting the etiology of the disease and appropriate drugs administration.
The primary immediate medical care should be directed to respiratory distress elimination and tissue hypoxia prevention. The patient should immediately be admitted to intensive care unit (according to the guidelines CURB-65). The pathological condition could be treated with oxygen supplementation via nasal prongs, face mask, or extracorporeal membrane management (Jain et al., 2015). The other approach consideration for dealing with respiratory distress could be mechanical ventilation. It could be helpful in order to ensure adequate gas exchange. The female should receive a tidal volume of 5 ml/kg in order to minimize alveolar wall stress as well as improve tissue oxygenation. A ventilator support for the patient could also be achieved via a full-face mask or nasal one, which provides positive airway pressure known as non-invasive positive-pressure ventilation (Rochwerg et al., 2017). Such a procedure, particularly, would be rather helpful in case of respiratory insufficiency caused by CAP or CHF as well as in patients with chronic obstructive pulmonary disease exacerbation. NPPV would provide sufficient PaO2 level in case of hypoxia or would serve as prophylaxis for respiratory distress progression.
Medication therapy should be prescribed after the final diagnosis is determined. In case of community acquired pneumonia the first-line therapy is based on antibiotics chosen via empirical method. According to the guidelines presented by Rochwerg et al. (2017), the adequate therapy includes cephalosporin, such as Ceftiaxone (500 mg twice a day intramuscularly) combined with macrolides, for instance, Erythromycin (500 mg twice a day intravenously). Respiratory fluoroquinolone could also be an alternative in case of allergy to penicillin: levofloxacin may be administered orally at a dose of 750 mg daily (Wunderink & Waterer, 2014). The antibiotic therapy should last from five to seven days depending on the level of clinical improvement. Probiotics should also be administered along with the antimicrobial drugs. One week after the antibiotics, discontinuation a repeat chest X-ray should be made in order to monitor the efficiency of the therapy as well as possible complications development.
Hospital discharge is appropriate when the patient is hemodynamically stable, does not show signs of respiratory distress, and has no active medical problems. The woman should be advised to drink at least 3.5 l of pure water in order to ensure adequate hydration of the body. What is more, the patient should preserve the cough reflex during the recovery period. The treatment and recovery should be supplemented with adequate diet rich in protein and micronutrients in order to maintain calories deficiency. Vaccination is also highly recommended for the patient after the recovery. Pneumococcal as well as influenza vaccines may increase the resistance of the body to bacterial and viral infections.
