WU Health and Medical A 67-year-old With Tachycardia and Coughing Case Study

After reviewing the case and the accompanying case analysis questions, included in the document, answer the 10 questions directly in the Case Assignment document. When providing evidence to support your answers, be sure they are evidenced-based, current (no more than 5 years old), and follow current standards of care. Follow APA 7th edition formatting.

Case Title: A 67-year-old With Tachycardia and Coughing
Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan.
Ms. Jones lives with her daughter and is able to perform all activities of daily living (ADLs)
independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she
has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per year history of smoking
cigarettes but quit smoking 3 years ago. Other known history includes chronic obstructive
pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. She also
reports some complaints of intermittent pain/cramping in her bilateral lower extremities when
walking and has to stop walking at times for the pain to subside. She also reports some pain to
the left side of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged
sputum. She states she has COPD and has been using her albuterol inhaler more than usual. She
says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of
breath. She admits that she has some weakness and fatigue but is still able to carry out her daily
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component
Glucose, Serum
Creatinine, Serum
Sodium, Serum
Potassium, Serum
Chloride, Serum
Carbon Dioxide
Protein, Total, Serum
86 mg/dL
17 mg/dL
0.63 mg/dL
120 mL/min
141 mmol/L
4.0 mmol/L
100 mmol/L
26 mmol/L
8.7 mg/dL
6.0 g/dL
4.8 g/dL
2.4 g/dL
1.0 mg/dL
17 IU/L
15 IU/L
Allergies: Penicillin
Current Medications:

Atorvastatin 40mg p.o. daily
Multivitamin 1 tablet daily
Losartan 50mg p.o. daily
CBC Component
White blood cell count
Mean Corpuscular Volume
Mean Corpus HgB
Mean Corpus HgB Conc
RBC Distribution Width
Platelet Count
5.0 x 10E3/uL
4.71 x10E6/uL
10.9 g/dL
79 fL
28.9 pg
32.5 g/dL
178 x 10E3/uL

ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
Caltrate 600mg+ D3 1 tablet daily
Diagnosis: Pneumonia
Directions: Answer the following 10 questions directly on this template.
Question 1: What findings would you expect to be reported or seen on her chest x-ray results,
given the diagnosis of pneumonia?
Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired
pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?
Question 3:

3A) What assessment tool should be used to determine the severity of pneumonia and
treatment options?
3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate
on each clinical factor for this patient.
Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your
treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?
Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring
airflow limitation?
Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having
to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential
diagnosis for this? Explain your reasoning.
DVT (Deep Vein Thrombosis)
Intermittent Claudication
Electrolyte Imbalance
Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having
to rest to stop the leg pain. What test could be ordered to further evaluate this?
Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.
Question 9: What patient education would you give Ms. Jones and her daughter? What would be
your follow-up instructions?
Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms.
Jones’ Pneumonia? Explain why or why not.

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