NRNP 6540 Assessing Cardiovascular and Pulmonary Disorders Assignment

 
 Example
Introduction

Ms. Baker, a 68-year-old woman, presents with a rapid heart rate and frequent coughing. With a medical history including chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, and vitamin D deficiency, she also experiences intermittent leg pain while walking, which subsides with rest. Given her recent symptoms, vital signs, and laboratory results, the following assessment and management plan will explore her diagnosis, treatment options, and education needs.

Question 1: Expected Chest X-ray Findings for Pneumonia

For a patient like Ms. Baker, who is diagnosed with pneumonia, common radiographic findings on her chest X-ray would likely include areas of consolidation, which represent fluid and pus-filled alveolar spaces due to infection (Marrie, 2018). Given her diagnosis of left lower lobe pneumonia, we would anticipate localized opacities or infiltrates within the left lower lobe. Additional signs may include air bronchograms or increased vascular markings due to inflammation in the affected lung tissue.

Question 2: Classification of Pneumonia – CAP vs. HAP

Ms. Baker’s pneumonia is best classified as community-acquired pneumonia (CAP). CAP is an infection acquired outside of a hospital or healthcare facility, typically diagnosed in patients presenting from the community with no recent healthcare exposure (Metlay et al., 2019). In contrast, hospital-acquired pneumonia (HAP) occurs 48 hours or more after admission to a healthcare setting (Mandell, 2020). Since Ms. Baker’s symptoms developed at home, her pneumonia aligns with CAP criteria.

Question 3: Assessment Tool and Application (CURB-65)

3A) The CURB-65 score is a widely used tool to assess pneumonia severity and guide treatment. It assigns points based on five factors: confusion, urea >7 mmol/L, respiratory rate ≥30, blood pressure <90/60 mmHg, and age ≥65 (Lim et al., 2010).

3B) In Ms. Baker’s case:

Confusion: Not present

Urea: Not elevated (BUN is 17 mg/dL)

Respiratory rate: Elevated at 22 breaths per minute but does not meet the ≥30 criterion

Blood pressure: Normal at 126/78 mmHg

Age: She is 68, scoring 1 point for age alone.

Based on her CURB-65 score of 1, Ms. Baker could likely be managed as an outpatient with oral antibiotics and close monitoring (Lim et al., 2010).

Question 4: Treatment Plan Based on CAP Guidelines

For Ms. Baker’s CAP, recommended treatment aligns with amoxicillin/clavulanate combined with a macrolide like azithromycin. The combination covers common CAP pathogens, including Streptococcus pneumoniae and Haemophilus influenzae (Metlay et al., 2019). Given her COPD history, this regimen is optimal as it addresses potential bacterial pathogens in COPD patients, who are at higher risk of secondary infections. Ms. Baker should also use bronchodilators, such as her ProAir HFA inhaler, to manage respiratory symptoms related to her COPD exacerbation (GOLD, 2023).

Question 5: Gold Standard for Measuring COPD Airflow Limitation

The gold standard for assessing airflow limitation in COPD patients is spirometry. Specifically, FEV1 (Forced Expiratory Volume in 1 second) measures airflow limitation severity (GOLD, 2023). Regular spirometry assessments will help monitor Ms. Baker’s disease progression and adjust her COPD management plan accordingly.

Question 6: Most Likely Diagnosis for Intermittent Leg Pain

The best diagnosis for Ms. Baker’s intermittent leg pain is intermittent claudication. Intermittent claudication is commonly associated with peripheral artery disease (PAD) and is characterized by leg pain or cramping during activity that subsides with rest (Criqui & Aboyans, 2015). Ms. Baker’s smoking history and hypertension further increase her PAD risk, making this diagnosis more likely than other options, such as DVT, cellulitis, or electrolyte imbalance, which have different symptom profiles.

Question 7: Diagnostic Test for Intermittent Claudication

To evaluate Ms. Baker’s suspected intermittent claudication, an Ankle-Brachial Index (ABI) test is appropriate. The ABI measures blood flow by comparing blood pressure in the ankle and arm, with abnormal values indicating PAD (Aboyans et al., 2018). Positive findings would prompt further vascular assessment and guide treatment to improve her walking tolerance.

Question 8: Differential Diagnoses for Initial Presentation

 	
COPD Exacerbation: Her increased cough and reliance on her inhaler suggest a potential COPD exacerbation, especially with a history of smoking and COPD (GOLD, 2023).
 	
Community-Acquired Pneumonia (CAP): Symptoms like cough, sputum production, and tachycardia align with pneumonia, a confirmed diagnosis through assessment.
 	
Heart Failure: Given her history of hypertension, heart failure should be considered as a differential, as it can manifest with fatigue, cough, and peripheral symptoms (McDonagh et al., 2021).

Question 9: Patient Education and Follow-Up

Education: Ms. Baker should be advised on the importance of medication adherence, including using her inhaler correctly and consistently taking her prescribed antibiotics. She should also receive education on recognizing symptoms of worsening COPD or pneumonia, such as increased shortness of breath or high fever, and on avoiding respiratory infections by practicing good hygiene and considering pneumococcal and influenza vaccinations (GOLD, 2023).

Follow-Up: Ms. Baker should be scheduled for a follow-up within 1–2 weeks to reassess her respiratory symptoms, confirm pneumonia resolution, and adjust her COPD treatment if necessary.

Question 10: Suitability of Amoxicillin/Clavulanate + Macrolide

Yes, amoxicillin/clavulanate plus a macrolide would be an appropriate choice for Ms. Baker’s CAP treatment. This combination targets both typical and atypical CAP pathogens and is recommended for patients with COPD due to their higher risk of infection by gram-negative and atypical bacteria (Metlay et al., 2019). However, given her penicillin allergy, alternative options should be considered, such as doxycycline or a quinolone, based on her allergy severity and response history.

Conclusion

Ms. Baker’s case highlights the need for comprehensive assessment and individualized care to address her respiratory and cardiovascular health needs. By following evidence-based guidelines and carefully considering her COPD and smoking history, her CAP can be effectively managed, and additional cardiovascular concerns, such as intermittent claudication, can be evaluated to improve her overall quality of life.

References

Aboyans, V., Ricco, J. B., Bartelink, M. L. E. L., et al. (2018). ESC Guidelines on the diagnosis and treatment of peripheral artery diseases. European Heart Journal, 39(9), 763-816.

Criqui, M. H., & Aboyans, V. (2015). Epidemiology of peripheral artery disease. Circulation Research, 116(9), 1509–1526.