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Case Study of Dudley Dawes: Development of pneumonia

Applied Bioscience GMED 2000 Assessment 1:  Integrated Case Study 

Patient profile:

Name: Dudley Dawes

DOB: 12/12/1942

Address: 18 Stridor Place, South Guildford WA 6055

Reason for admission: 

Dudley is an inpatient on the Curtin surgical ward after sustaining a # Right Neck Of Femur injury whilst bowling. He has had a Right Total Hip replacement (THR) and is now day 7 postoperatively  and recovering in hospital. For the past 2 days Dudley reports having a productive cough, fever, night chills, shortness of breath and difficulty breathing. 

Vital signs:

Temperature 38.6 ◦C

Respiratory Rate 32 breaths/min. Inspiratory stridor apparent. 

Pulse 110 beats/min, regular, bounding pulse.

Blood Pressure 150/80 mmHg

SaO2 92% on room air

Current condition: 

Short of breath on exertion, difficulty speaking and fatigued. Difficulty sleeping and decreased appetite over the past 3 days. Dudley states he initially felt as though he was ‘getting a cold’, but has been coughing up thick green mucopurulent sputum regularly.

Past Medical History:

Hypertension

Hyperlipidemia

Type 2 Diabetes

IHD

Arthritis

COPD – Smoker: 10 cigarettes per day

Constipation

Nil known allergies

Medications:

Salbutamol Inhaler 2 puffs every 4-6 hours prn

Ipratropium Bromide 2 puffs (21 micrograms per dose) QID 

Atenolol 50mg tablet PO daily

Ramipril 2.5mg PO daily

Coloxyl and Senna 2 tablets PO daily

Atorvastatin 40mg tablet PO nocte

Metformin 500mg PO BD

Glicazide 60mg PO daily

Omeprazole 20mg PO daily

Warfarin 5mg PO daily

Clexane 80mg SC BD

Paracetamol 1g PO 6hrly prn

Endone 5-10mg PO 3-4hrly prn (postoperatively not while on PCA)

Oxycontin 10mg PO 6hrly prn (postoperatively not while on PCA)

Nutritional assessment: 

Dudley lives alone and prepares his own meals.  His daughter takes him shopping once a week. 

Spiritual, cultural needs: 

Noongar Aboriginal descent. Attends bowls club regularly.

Social history:

Retired Gardener. Grew up in an Aboriginal mission, Moore River Native Settlement.

Widower for 10 years. 3 children. Patient lives alone in the well-equipped single story family home. No internal steps.  Patient has no problems with hearing or communication, but wears glasses for reading. Drinks 1-2 beers/day.

Self Care / Mobility:

Patient can usually transfer independently and is normally mobile. When well Dudley continues to drive and participates in local community clubs. His mobility is currently impaired following surgery (R THR) and he requires assistance with ADL’s. Dudley smokes 10 cigarettes per day. No hearing or communication problems.

Support agencies: 

OT to arrange home visit.

Pressure Areas Risk Assessment: Braden Score= 10 postoperatively following R THR

INTEGRATED CASE STUDY REPORT QUESTIONS:

PLEASE ANSWER THE QUESTIONS BELOW, IN RELATION TO THE CASE STUDY PROVIDED

1500 words limit - 

CONTENT FOCUS (25 marks):

Focus Area One (9 marks) Aetiology and pathophysiology

  1. Describe in brief the aetiology of Pneumonia – out of 3 marks
  2. Describe in brief the pathophysiology of Pneumonia – out of 4 marks
  3. Relate this back to the Case study provided – out of 2 marks

Focus Area Two (9 marks) - Clinical signs and symptoms and clinical assessment. 

  1. Describe the typical signs and symptoms of Pneumonia – out of 3 marks
  2. Discuss the full clinical assessment of a patient presenting with Pneumonia (Include patient history & physical examination) – out of 4 marks
  3. Relate this back to the case study provided – out of 2 marks

Focus Area Three (7 marks) - Identify actual and potential patient risks (complications)

  1. Discuss in brief ONE short or long term potential complication (One Complication) related to Pneumonia  - out of 2 marks
  2. Outline recommended management strategies for this complication identified – out of 3 marks
  3. Relate this back to the case study provided – out of 2 marks

Answer

Case study of Dudley Dawes

  • Focus Area 1:

Aetiology of pneumonia 

Pneumonia is considered an inflammatory condition of the lung which can affect the small air sacs known as alveoli. Pneumonia can be used to describe any inflammation of the lungs (American Lung Association, 2018)

The inflammation can be initiated by the microorganism like bacteria, fungus, virus, or bacteria-like an organism.  Therefore, the common cause of bacterial pneumonia is Streptococcus pneumonia (World Health Organization, 2018). These organisms can infect the lung after having a cold or flu. It can affect the lobe of the lung. Thus, Mycoplasma pneumonia is also responsible for developing pneumonia in human. It is a bacterium-like an organism which can produce mild symptoms of pneumonia. This type of pneumonia is considered mild pneumonia which can be treated easily. In addition, people with chronic health problems or multiple diseases which weakened their immune system are prone to develop fungal pneumonia. The responsible fungi are present in soil and bird dropping. However, it is restricted in specific geographic areas. Therefore, few viruses are responsible for flu and cough. They can precipitate pneumonia in human. It is a common type of infections among the children. It can be considered mild but in some cases, it can be fatal. Additionally, it has been isolated that some people are acquired pneumonia during their hospital stay. In such cases, bacterial pneumonia has been isolated (Mayo Clinic, 2018). This kind of pneumonia is required an emergency response as the responsible bacteria can be more resistant to antibiotic treatment and poor immunity adversely can affect the whole situation. In addition, people admitted to ventilation are often developed this kind of pneumonia in hospital settings.         

Pathophysiology of pneumonia

The pathophysiology of pneumonia stated that the invading organism can provoke the exuberant immune response in the lungs. Therefore, the blood vessels in the lungs become leaky and protein-rich fluid can deposit in alveoli (Science.jrank, 2018). As a result, less functional area for the gas exchange can deprive the patient of oxygen. Thus, the patient can feel rapid and fast breathing and require more effort to inhale oxygen and exhale carbon dioxide. In addition, mucus production is also increased. Thus, the leaky blood vessels can tinge the blood with the mucus. Therefore, the mucus plugs can farther decrease the gas exchange procedures in the lungs (Science.jrank, 2018) . In such condition, large numbers of white blood cells are produced to fight against the infections, however, make the alveoli fill with fluid and debris. In bacterial pneumonia, alveoli of the lungs get affected and in viral pneumonia, the wall of the alveoli and the parenchyma of the lungs get affected (Science.jrank, 2018).                

Relate to the Case study 

In the case of Dudley smoking and COPD can play a vital role in the development of pneumonia. It has been identified that the Streptococcus pneumoniae infection is very common among the COPD patients (Almirall, Blanquer & Bello, 2014). It has been established that the adherence of Streptococcus pneumoniae to the epithelial cells of the oral cavity of the smokers can persist for years after cessation of smoking. Therefore, in the case of Dudley, smoking can impair his immune strength and increase the risk of pneumonia (Almirall, Blanquer & Bello, 2014).    

Therefore, his COPD is also enhancing the complication and chances of pneumonia. Dudley has suffered from type 2 diabetes which can reduce his immunity and make him prone to develop infectious diseases. High glucose level can provoke the bacteria to generate pneumonia (Kornum et al., 2007).  It can be assumed that poor immune system of Dudley due to several health disorders and diseases makes him susceptible for developing pneumonia by the opportunity bacteria like Staphylococcus aureus, Klebsiella pneumoniae, and  Pseudomonas aeruginosa (Healthline, 2018). 

  • Focus Area 2

Sign and symptoms of pneumonia 

The sign and symptoms of pneumonia can vary according to the severity of the disease the type of infections and the age of the patient. General sign and symptoms are chest pain, cough, and fatigue; poor mental status, fever, sweating, shaking, and low body temperature along with shortness of breath, nausea and vomiting (WebMD, 2018).  

The symptoms of lung infections are slower than flu but faster than cold. The germs are getting down into the lung and cause further infections.  Therefore, pneumonia has common symptoms like flu but it also has a high fever, greenish cough, bloody mucus, breathlessness, low appetite, fast heartbeat (WebMD, 2018)

Clinical presentation of pneumonia

 Physical Examination

The findings of Physical examination can vary depending on the severity of the disease, type of infections, the presence of complications, and coexistence of host factors (WebMD, 2018). The physical finding can reveal the following situation-

  • Breathing with inconvenient sounds.
  • Egophony
  • Decreased intensity of breathing sounds.
  • Tracheal deviation
  • Lymphadenopathy
  • Pleural friction rub

The examination finding can indicate specific etiology of the disease. Therefore bradycardia can indicate Legionnaires disease, bullous myringitis can indicate Mycoplasma pneumoniae infection, evident of aspiration can include a decreased gag reflex and CNS findings can suggest the Nocardia infection.  

History

History would help to identify the potential exposure, aspiration risk, and host factors of the patients. 

  • Potential exposure

history of various exposures would help in determining the possible chance of infections (Thompson, 2016). Therefore, the important criteria’s are-

  • Exposure to contaminated air or water causes infection due to Legionella species.
  • Exposure to overcrowd atmosphere can increase the chances of S pneumoniae, Mycobacteria, and Mycoplasma infections.
  • Exposure to a domestic animal can increase the incident of C psittaci and  F tularensis infections.  
  • Aspiration risk

Increased risk of Aspiration can also increase the incidence of secondary pneumonia infections. Therefore, consumption of alcohol, drug, poor mental health, congenital abnormalities, dysphagia along with seizure and Gastroesophageal reflux disease (GERD) can increase the chances of infections in human (Thompson, 2016).

  • Host factors 

Past medical history of the patient should get utmost priority as they have a strong relation with disease development. Therefore, asthma, COPD along with smoking and alcohol consumption can elevate the chances of pneumonia. In addition, analysis of medication along with social and family history would help in proper identification of the scenario (Medscape, 2018 

Relate to a case study

In the case of Dudley, it has been observed that he has a mild fever as the body temperature is 38.6o C, his Respiratory Rate is quite high as he has breathing difficulties. Therefore, he is suffering from tachycardia due to high pulse rate along with high BP and shallow breathing. He has difficulties in communicating, loss of appetite and fatigue. The all above symptoms are indicating that he is suffering from pneumonia which needs emergency treatment. In the initial stage he thought that he might have a cold but gradually the cough becomes thick and green.

As Dudley was a heavy smoker and have COPD and Asthma. Thus the chances of infections are increased in many folds. In addition, he has Type 2 diabetes which can interfere with his immune system and make him vulnerable to infectious diseases. Additionally, his arthritis can also play a role in the development of pneumonia (Kelly, 2017)However, he is advised to take several medicines to improve his conditions but few drugs have some side effects which adversely affect the scenario. In this consent, Endone is a medicine used to relieve pain can cause sneezing and weakness (NPS MedicineWise, 2018). Omeprazole is a medicine used as a proton pump inhibitor to reduce the complication of GERD can often precipitate cold and cough along with fever (Cunha, 2017). Additionally, Ramipril is used to treat hypertension can cause a cough and poor immunity (Healthline, 2018). The inhaler Ipratropium Bromide used for a cough and cold symptoms are often participated sneezing and cough (Cunha, 2016).       

Therefore, Dudley is an aboriginal widower with several diseases. His loneliness and morbid condition along with poor nutritional status and immunity can make him vulnerable to pneumonia. However, proper medical intervention can improve his situation gradually.    

  • Focus Area 3

Potential complication of pneumonia

 Pneumonia can cause Acute Respiratory Distress Syndrome (ARDS) which is considered as a severe lungs condition. In this situation air sacs are filled with fluid as a result fluid in the lungs can increase the carbon dioxide in the blood and lower the amount of oxygen (Healthline, 2018). Therefore, the vital organs are deprived of oxygen which is essential for their proper function and ultimately causes organ failure. Thus, ARDS can cause severe trauma in hospitalized patients and considered as life-threatening, an emergency condition (Healthline, 2018). 

The common symptoms of ARDS are rapid breathing, fatigue of muscles, weakness, low blood pressure, discoloration of skin and nails, dry cough, and fever along with a headache, rapid pulse rate, and confusion. The risk factors for ARDS are old age, chronic lung infections, alcohol consumption, and smoking. It can create serious illness among the old age people, a patient with liver disease, and toxic shock (Healthline, 2018).             

Management strategies for the complication

ARDS can be managed in the following way-

  • Supply of Oxygen 

The primary goal of the treatment is based on providing enough oxygen to avoid organ failure. In this aspect, mechanical ventilation machine or oxygen mask can be used. In this way force of air into the lungs can reduce the fluid present in sacs (Han & Mallampalli, 2015).

  • Maintenance of body fluid

Maintenance of adequate fluid balance is essential in case of ARDS. Too much fluid intake can increase the fluid build-up in the sacs. However, water insufficiency can cause organ failure (Bein et al., 2016)

  • Medication

In case of ARDS few medications can be administrated to relive the complication (Healthline, 2018). In this respect antibiotics are administered to treat infections, analgesic drugs can be used to relieve the discomfort and blood thinner medicines can be given to avoid clotting in lungs.   

  • Pulmonary Rehab 

The recovering process of ARDS needs pulmonary rehabilitation. This process of rehabilitation can strengthen the respiratory system by increasing lungs capacity (Bein et al., 2016). In this aspect life style modification, exercise, and proper training can be beneficial.   

Relate to a case study

Aging is responsible for significant changes in the respiratory system and the gas exchange process (Aplaceformom, 2018). Therefore the structural changes of lungs and chest wall are responsible for the alteration. In the case of Dudley, age is a concerning factor which can cause ARDS which can create an additional burden on his respiratory system and functioning. Thus, his COPD is responsible for obstructive airflow which can enhance the chances of ARDS. In addition, increasing age is accountable for lower arterial PO2 due to reducing of alveolar surface, closure of airway, and a decrease of diffusion capacity of lungs (Aplaceformom, 2018).  Any disease of lungs or injuries can develop ARDS. Therefore, the collapse of alveoli due to reducing surfactant can interfere with oxygen exchange of the blood and cause hypoxemic respiratory failure (Aplaceformom, 2018). In Dudley, the previous case history of COPD and habit of smoking can interfere with the occurrence of the collapse of alveoli. If Dudley develops ARDS, then the lack of oxygen in the blood can produce cytokines by the injured lungs and WBC which can lead to inflammation in the vital organs. As he has already suffered from several diseases, ARDS can adversely affect the whole scenario of recovery (Mercola, 2018).    

The decrease in the level of oxygen in the blood caused by ARDS can cause leakage of certain proteins (cytokines) in the bloodstream which is produced by the injured cell of the lungs and white blood cells. Therefore, it can lead to inflammation and other complications in the vital organs (Patel, 2018) and can cause multi organ failure situation. Therefore, patients suffering from ARDS are unable to fight against the pathogens and as a result develop infectious diseases.

At last it can be concluded that the physical condition of Dudley is clearing showing the symptoms of hospitalised pneumonia which can be treated by emergency medical intervention. In many cases, it has been observed that untreated pneumonia could precipitate severe complication which can be life threatening. Thus, early detection in case of Dudley could be beneficial; however, other physical complications of Dudley can delay the recovery process. He has COPD and Diabetes which can adversely affect the recovery process of pneumonia. Therefore, early identification and quick intervention is essential for treating pneumonia.  

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