Case Study Presentation
Review the case study provided by
Reflect on the patient’s symptoms and aspects of disorders that may be present.
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history?
Include a list of prescription and over-the-counter drugs the patient is currently taking.
Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out.
Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits.
Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors.
Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses.
Case Study
EW is a 67 years old female with history of hypertension, chronic obstructive pulmonary disease with chronic respiratory failure, moderate pulmonary hypertension, currently on tadalafil and ambrisentan as outpatient.
Patient had 2D echo done on previous admission which showed ejection fraction greater than 70%.
Patient present to the ER with respiratory distress oxygen saturation in the 70’s on room air, which improved significantly when placed on BiPAP on 70% FiO2 saturating at 97%.
Patient currently appears comfortable with no significant respiratory distress while on BiPAP.
Currently no significant wheezing was noted. Patient stated that she noted to have shortness of breath with wheezing and cough for 3 days.
Patient denies chest pain, palpitation, lightheadedness or dizziness, no nausea or vomiting associated with symptoms. Denied any fever and chills.
Allergies: Lisinopril, penicillin
Medication:
Ambrisentan 10 mg oral tablet, 10 mg, po daily
Amlodipine, 10 mg,= 1 tablet, po daily
Tadalafil, 40 mg, po, daily
Solu-medrol , 125 mg = 1mL, IV push, q 6hrs
Tamiflu 75 mg b.i.d.
Albuterol, 2.5 mg= 3 ml , NEB, q4hr, prn
DuoNeb 0.5 mg-2.5 mg/3Ml inhalation solution, 3 mL, NEB, q6hrs
Tylenol, 650 mg= 2 tabs , po, q 4hr, prn
Assessment/Plan
1. Acute respiratory failure:
Acute hypoxic hypercapnic respiratory failure due to COPD exacerbation with moderate to severe pulmonary hypertension and pneumonia due to Influenza A.
ABG done showed pH of 7.32 with PCO2 of 60. Currently on BiPap on FIO2 70% suturing 97%. Patient received DuoNebs q 6hrs and prn, Solu-Medrorol 125 mg IV q6 hours, for shortness of breath, incentive spirometry, Tamiflu 75 mg b.i.d., vancomycin and Levaquin.
We will continue IV vancomycin and Levaquin pending cultures. We will follow-up with blood culture, procalcitonin level, urine cultures. Troponin x3 negative. We will try to wean of BiPAP.
2. COPD exacerbation
COPD with acute exacerbation has chronic respiratory failure with hypoxia due to chronic obstructive pulmonary disease and moderate to severe pulmonary hypertension. On home O2 4L nasal cannula baseline.
3. Influenza A.
Continue Tamiflu
4. Pneumonia
-likely due to influenza
Social History:
Former Smoker, quit more than 30 days ago
Family History:
Hypertension: Father
Labs
WBC 12.8 x10(3)/mcl (High)
RBC 5.35 x10(6)/mcL (High)
Hgb 15.7 G/dL
Hct 49.1% (High)
Platelet 242 x10(3)/mcL
Sodium level 138 mMol/liter
Potassium 4.3 mMol/liter
Chloride 101 mMol/liter
CO2 32 mMol/liter
BUN 20 mg/dL
Creatinine 0.76 mg/dL
BNP 37 pg/mL
Influenza A DETECTED
Influenza B Not Detected
RSV RNA Not Detected
COVID 19 Not Detected
Diagnostic Results
XR Chest 1 View for Shortness of Breath
Findings suggestive of Moderate Pulmonary edema; cannot exclude superimposed interstitial pneumonia.