Case Study: Middle-aged Patient with Productive Cough, Chills

NURS 6531: Primary Care of Adults Across the Lifespan | Week 5

Respiratory disorders can often be well managed when properly diagnosed and treated. As an advanced practice nurse, you must know when to treat, when to order diagnostics, and when to refer for specialized care. Consider a 33-year-old patient, Eileen Rubin. Rubin presented with difficulty breathing and lower back pain. Rather than ordering diagnostics such as blood tests, chest x-rays, or pulmonary function testing, the provider prescribed muscle relaxers for the pain. After her condition worsened, she sought care from another provider who immediately ordered a chest x-ray and blood work. Following the diagnostic testing, she was admitted to the intensive care unit and was diagnosed with sepsis and acute respiratory distress syndrome. She spent weeks in a drug-induced coma and suffered from a collapse of both lungs (Rubin, 2012, p. 34–36). As this case outlines, you must carefully diagnose and treat patients, as failure to order the proper diagnostic tests could result in the loss of a patient’s life.

This week, you examine patient x-rays and distinguish between normal and abnormal x-ray results. You also explore the use of COPD diagnosis, management, and prevention strategies suggested in the clinical guidelines. Finally, you consider patient diagnoses and treatment based on pulmonary function test results.

Learning Objectives – NURS 6531: Case Study: Middle-aged Patient with Productive Cough, Chills

By the end of this week, students will:

• Assess differential diagnoses for patients with Respiratory disorders
• Analyze the role of patient information in differential diagnosis for Reparatory disorders
• Assess patient diagnoses according to x-ray results
• Evaluate patient treatment options for Respiratory disorders
• Understand and apply key terms, concepts, and principles related to Respiratory disorders
• Analyze pattern recognition in patient diagnoses

Learning Resources

Required Readings

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

• • Part 4, “Office Emergencies”

• • • Chapter 24, “Acute Bronchospasm” (pp. 192-194)

This chapter explores the epidemiology, pathophysiology, and clinical presentation of acute bronchospasm. It also describes the roles of physical examinations, diagnostics, and differential diagnoses in management of acute bronchospasm.

• • Part 10, “Evaluation and Management of Pulmonary Disorders” (pp. 417-503)

This part outlines examination and treatment components of pulmonary disorders, such as acute bronchitis, asthma, chest pain, chronic cough, COPD, dyspnea, lung cancer, pleural effusions, and pneumonia. Lifespan considerations, complications, and health promotion strategies are also examined.

• • Part 20, “Evaluation and Management of Infectious Disease”

• • • Chapter 235, “Tuberculosis” (pp. 1262-1271)

This chapter differentiates between active and latent tuberculosis and examines components that aid in diagnosing and managing tuberculosis, including pathophysiology, clinical presentation, and diagnostics.

Global Initiative for Chronic Obstructive Lung Disease. (2017). At-a-glance outpatient management reference for chronic obstructive pulmonary disease (COPD).Retrieved from http://goldcopd.org/wp-content/uploads/2016/11/wms-At-A-Glance-2017-FINAL.pdf

This article outlines the COPD guidelines and includes guidance for diagnosis, assessment, and management of patients with COPD.

University of Virginia. (n.d) Introduction to radiology: An online interactive tutorial. Retrieved from

Discussion: Examining Chest X-Rays

Chest x-rays are an invaluable diagnostic tool as they can help identify common respiratory disorders such as pneumonia, pleural effusion, and tumors, as well as cardiovascular disorders such as an enlarged heart and heart failure. As an advanced practice nurse, it is important that you are able to differentiate a normal x-ray from an abnormal x-ray in order to identify these disorders. The ability to articulate the results of a chest x-ray with the physician, radiologist, and patient is an essential skill when facilitating care in a clinical setting. In this Discussion, you practice your interprofessional collaboration skills as you interpret chest x-rays and exchange feedback with your colleagues.

Consider the three patient case studies and x-rays

Note: By Day 1 of this week, your Instructor will assign you to post on one of these patient case studies and x-rays:

Case Study 1

35-year-old Asian male presents to your clinic complaining of productive cough for two weeks. Stated he has had mild intermittent fever with myalgia, malaise and occasional nausea.

• SH: works as a law clerk
• PE: NP noted low grade fever (99 degrees), with very mild wheezing and scattered rhonchi.

Case Study 2

This is a 44-year-old Caucasian male being seen at your clinics with complaints of complaints of cough for 4 days and worsening. Stated he has had high grade fever. States he feels weak and has been in bed most of the last two days. Complains of exertional dyspnea, followed by dyspnea at rest, non-productive cough and pleuritic chest pain

• MEDS: Zovirax, Diflucan, magic mouth wash, Zofran, mycostatin, filgrastin
  PMH: HTN, Hep C, HIV/AIDS, thrush
  SH: Past IV Drug abuse; lives in a group home;
  PE: VS: Ht: 5’7, Wt: 150#, BMI 23,

Anorexic male, febrile, tachypneic, tachycardic, with rales and rhonchi. You note decreased in breath sounds, dullness, and egophony

Case Study 3

•  A 50 year old Caucasian female presents to the clinic with complaints of cough for almost 2 weeks. Positive productive green sputum with associated chills, sweating, and fever up to 101.5. She manages a daycare and states that many of the children have had upper respiratory symptoms in the last two weeks. PMH: DM diagnosed 7 years ago, controlled on medications.
• MEDS: Glyburide 10mg qd
• PE: She looks ill with continuous coughing and chills.
• BP 100/80, T: 102, HR: 110; O2Sat 97% on RA.
• Lungs: +Crackles, increased fremitus
• Labs: CBC 17,000 cells/mm3 , blood sugar is 120

To prepare:

• Review Part 10 of the Buttaro et al. text in this week’s Resources, as well as the provided x-rays.
• Reflect on what you see in the x-ray assigned to you by the Course Instructor.
• Consider whether the patient in your assigned x-ray has an enlarged heart, enlarged blood vessels, fluid in the lungs, and/or pneumonia in the lungs.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

By Day 3

Post an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study you were selected or were assigned. Describe the role the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days who selected or were assigned a different case study than you did by providing additional observations and insights. Respond to questions posed to you during the week. NURS 6531: Case Study: Middle-aged Patient with Productive Cough, Chills