FOCUSED CASE STUDY 2
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CaseStudy13_lewis_sample.docx2
Case Study # 1
Name
Institution
Course
Tutor
Date
CHIEF CONCERN
"I am having fever and back pain."
HISTORY OF PRESENT ILLNESS
A 72-year-old female patient approaches her regular primary care physician (PCP) after experiencing lethargy, malaise, and fever over the past two days. She awoke with a dull ache in her right mid-back and nausea, prompting her return since she was concerned about the discomfort and growing symptoms. Her symptoms reoccur despite resting and the use of acetaminophen (650 mg every 4 to 6 hours), which offers brief relief. Although unaware of her fever's actual degree, she states that the agony is a 3 or 4 out of 10. Her daily routine has been substantially interrupted by her exhaustion, malaise, and nausea, which has kept her in bed for most of the prior day and all of today.
Despite receiving the flu vaccine three weeks ago, she fears she has it. Her primary concern derives from living alone and dreading contracting a severe illness without prompt medical attention. The patient is a nonsmoker who drinks alcohol only occasionally. Her husband died of prostate cancer eight years ago, and she now lives alone in her apartment. She has three children, one of whom lives close by and pays frequent visits. The patient is not sexually active at the moment. Although she reports increased urine frequency and urgency, she says she has no pain while urinating. She denies any sick contacts or changes in her eating habits.
PAST MEDICAL HISTORY
Adult illness:
· Medical: HTN and Osteoporosis
· Surgical: No history of medical surgical procedure.
· OB/Gynecological: She has three children who are alive.
· Psychiatric: None
Current medications:
· Lisinopril or hydrochlorothiazide 10/12.5 mg daily for the management of his hypertension condition.
· Weekly Alendronate 70 mg for the management of osteoporosis
· OTC calcium citrate 1,000 mg with 600 IU vitamin D3 daily for the management of her osteoporosis
Allergies: No known allergic reactions to medication, environment, and food.
· Immunization: The immunization is up-to-date.
PSYCHOSOCIAL
J.L. is a 72-year-old woman who lives in her apartment. She has suffered the death of her husband, who died of prostate cancer eight years ago. This occurrence may have emotional ramifications, and her living alone may contribute to her fears of becoming dangerously ill without rapid medical attention. Her freedom is an integral part of her psychological environment.
FAMILY HISTORY
Both parents died, and the mother reported dying due to type 2 diabetes. The husband died of prostate cancer. The three children are healthy with no chronic conditions.
REVIEW OF SYSTEMS
General: She admits fatigue, malaise, and fever. She also admits to experiencing dull aches in the right mild back and nausea.
Skin: She denies rashes, dryness, sores, lumps, itching, and color change.
HEENT (Head, Eyes, Ears, Nose, and Throat):
Head: She denies any headache . Eyes: denies loss of vision, wearing of the supportive lenses, and blurry vision. Ears: She denies ear discharge and pain. Nose and sinuses: denies running or stuffy nose or discharges. Throat (or mouth and Pharynx): She denies difficulty in swallowing, hoarseness, sore throat, or redness in the throat.
Neck: Denies the stiffness of the neck, goiter, or presence of lumps.
Breast: J.L. denies the presence of lumps, pain, or a feeling of discomfort or nipple discharge.
Respiratory: Endorses "occasional cough, but denies shortness of breath, wheezing, and pain during breathing.
Cardiovascular: admits a history of hypertension and a family history of coronary artery disease.
Gastrointestinal: Denies any constipation, diarrhea, or vomiting. She endorses frequent right flank pain.
Peripheral Vascular: reports no presence of cramps, varicose veins, swelling in the legs or feet, or changes in the color of the fingertips or toes during cold weather.
Urinary: She endorses increased urinary frequency and urgency but denies pain during urination.
Musculoskeletal: endorses frequent knee pain
Psychiatric: Denies changes in memory, suicidal ideation or thoughts, or attempts.
Neurologic: denies changes in mood, memory, judgment, dizziness, blackouts, headache, or seizures.
Hematologic: She reports no bruises, anemia condition, or bleeding.
Endocrine: She denies intolerance to cold or heat and night sweats. Denies polyuria or polydipsia.
PHYSICAL EXAMINATION
General survey: J.L. is a 72-year-old patient oriented to time, place, person, and event.
Vital signs: T 38.4, Pulse 95, R 14, Blood Pressure 107/69 mmHg, Weight 55.8, Height 170.2
Skin: She had warm, dry, and intact skin with no rashes or lesions. There is no clubbing or cyanosis of the nails.
Head, Eyes, Ears, Nose, Throat (HEENT): Head: no normocephalic or atraumatic head. Eyes: The confrontation reveals full vision. There is a pinkish conjunctiva with a whitish sclera. Ears: There is a normal tympanic membrane with no evidence of discharges. Nose: pinkish mucosa with midline septum and no nasal polyps or discharge. Mouth: There is pinkish oral mucosa, which is moistened and intact. There is bilateral tonsillar exudates pharynx.
Neck: There is no lymphadenopathy with a supple neck supple. There is a midline trachea with thyroid that has no nodule or goiter.
Lymph nodes: no lymphadenopathy on palpation.
Cardiovascular: No murmur auscultated, no splitting of S3 or S4, No orthopnea, palpitations, or dyspnea.
Breasts: No masses or lesions bilaterally.
Abdomen: there is a presence of flat, normoactive bowel sounds in all the quadrants with no masses detected.
Genitalia/Rectal: No mass or lesions detected in the cul-de sac or adnexa. There is a small uterus, which is also smooth.
Musculoskeletal: No tenderness of the vertebral processes was detected.
Neurologic: Mental Status: Alert and cooperative.
. DIFFERENTIAL DIAGNOSIS
Primary Diagnosis
Pyelonephritis: The patient's symptoms of fever, weariness, malaise, right mid-back discomfort, nausea, and increased urinary frequency and urgency point to a urinary tract infection (UTI) with kidney involvement (pyelonephritis) (Belyayeva & Jeong, 2022). Because of the right flank pain and the lack of respiratory symptoms, pyelonephritis is a likely main diagnosis.
Influenza (Flu): The patient suspects catching the illness despite vaccination. While the flu normally causes systemic symptoms such as weariness and malaise, it also causes respiratory symptoms such as cough and rhinorrhea (Centers for Disease Control and Prevention, 2019). However, the possibility of an unusual presentation cannot be ruled out and must be considered.
Musculoskeletal Strain: Musculoskeletal strain or injury could cause occasional knee pain and right mid-back pain (National Academies of Sciences et al., 2020). However, the systemic symptoms and increasing urine frequency point to a more extensive clinical picture than a localized musculoskeletal problem.
Gastrointestinal Infection: Gastrointestinal infections can cause fever, nausea, and stomach pain (Sattar & Singh, 2019). However, the symptoms, which include right mid-back pain and increased urine frequency, are unusual for a gastrointestinal infection. This is also less likely in the absence of vomiting or diarrhea.
Urinary Tract Infection: A UTI, mainly if located in the lower urinary tract, may cause increased urine frequency and urgency (Bono & Reygaert, 2021). On the other hand, the presence of fever, right mid-back discomfort, and systemic symptoms suggest a more severe involvement, maybe reaching the kidneys (pyelonephritis), and should be considered in the differential diagnosis.
Plan of care
Treatment
Pharmacology
Ciprofloxacin:
Ciprofloxacin 500 mg twice daily and it is provided in the tablets in common strengths include 500 mg. Ciprofloxacin is often administered via oral method. In extreme situations or in hospital settings, however, intravenous administration may be recommended. The duration of ciprofloxacin treatment for a urinary tract infection will be 10 days.
Ondansetron:
It is administered in doses ranging from 4 mg to 8 mg in tablet form. It is used orally in the form of pills or orally disintegrating tablets (ODT). In severe situations of nausea and vomiting, intravenous (IV) administration is also a possibility. The duration of ondansetron treatment will be determined by the severity of nausea and vomiting symptoms. The patient's response to the drug and the course of their underlying disease will determine the entire length.
Non-pharmacology
Non-pharmacological interventions are crucial for supporting renal function and facilitating infection flushing. Encouraging fluid intake helps maintain urinary flow and eliminate bacteria. Monitoring for signs of dehydration is essential for optimal recovery. Adequate rest is crucial for recovery from fatigue and malaise. A restful period improves healing and energy levels (Lo et al., 2021). A warm compress to the right mid-back area is recommended for comfort and pain relief, complementing pharmacological interventions in the overall care plan. This non-pharmacological measure aims to alleviate pain associated with the infection.
Patient Education.
The patient education component of the care plan should emphasize the importance of medication adherence, hygiene practices, and adequate fluid intake. To prevent antibiotic resistance, it is crucial to inform the patient about the need to complete the prescribed course of antibiotics, even if symptoms improve before completion. Maintaining good personal hygiene, especially in the genital area, is essential to reduce the risk of bacterial contamination and infections. Sufficient fluid intake helps promote urinary flow and flushing out of the bacteria from the urinary tract (Vaismoradi et al., 2020). Lastly, patient education should include awareness of warning signs that may indicate a worsening infection or potential complications, such as persistent high fever, severe pain, or changes in urinary symptoms. This empowers the patient to participate in their care actively and facilitates early intervention in case of any concerning developments.
Follow up
Follow-up care is crucial for a patient's recovery and effective condition management. A clinical follow-up appointment is recommended within 48 to 72 hours to assess antibiotic response and make necessary adjustments. Laboratory tests, specifically urine culture and sensitivity tests, are ordered to confirm infection resolution and guide further treatment adjustments. The patient is encouraged to monitor symptoms actively and report any concerns, facilitating ongoing assessment and timely intervention (Monegro et al., 2022). If no improvement is seen or complications are suspected, referral to a specialist is considered for comprehensive care after four days of the discharge. This comprehensive follow-up strategy aims to track progress, address emerging issues, and optimize the patient's overall health outcomes.
References
Belyayeva, M., & Jeong, J. M. (2022). Acute pyelonephritis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519537/
Bono, M. J., & Reygaert, W. C. (2021). Urinary Tract Infection. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29261874/
Center for Disease Control and Prevention. (2019). Seasonal Influenza Vaccine Safety: A Summary for Clinicians. Influenza (Flu). https://www.cdc.gov/flu/professionals/vaccination/vaccine_safety.htm
Lo, J. A., Kim, J. S., Jo, M. J., Cho, E. J., Ahn, S. Y., Ko, G. J., Kwon, Y. J., & Kim, J. E. (2021). Impact of water consumption on renal function in the general population: a cross-sectional analysis of KNHANES data (2008–2017). Clinical and Experimental Nephrology, 25(4), 376–384. https://doi.org/10.1007/s10157-020-01997-3
Monegro, A. F., Muppidi, V., & Regunath, H. (2022). Hospital Acquired Infections. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441857/
National Academies of Sciences, E., Division, H. and M., Services, B. on H. C., & Treatment, C. on I. D. M. C. L. to I. with. (2020). Musculoskeletal Disorders. In www.ncbi.nlm.nih.gov. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK559512/
Sattar, A., & Singh, S. (2019, March 8). Bacterial gastroenteritis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513295/
Tehrani, S., Elyasi, F., & Abolghasemi, S. (2020). Levofloxacin versus ceftriaxone for treatment of acute pyelonephritis in Iranian adults. Infectious Disorders Drug Targets, 21(4). https://doi.org/10.2174/1871526520999200727154214
Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ Adherence to Patient Safety principles: a Systematic Review. International Journal of Environmental Research and Public Health, 17(6), 1–15. https://doi.org/10.3390/ijerph17062028
