NU-664B Week 3 Discussion 1: Hispanic / Nondocumented Patient with Acute Illness

Differential Diagnosis:

1.      Community acquired pneumonia (CAP) – The is the most likely diagnosis for this patient. Subjective findings for this patient include many of the symptoms that are commonly reported in CAP including cough, fatigue, fever, chills, and sore throat (Dunphy et al.,2019). This patient has risk factors for pneumonia which include age greater than 65, the fact that she is a smoker, the fact that she has not been immunized against pneumonia, her asthma history, and the fact that she lives with extended family including elderly and infants (Mendez-Brich et al., 2019). The fact that she has hemoptysis also supports the diagnosis of pneumonia because one of the most common causes of hemoptysis is respiratory infections such as pneumonia ( O’Gurek & Choi, 2022). Annually CAP develops in 5 million people in the United States ( Dunphy et al., 2019). Worldwide CAP is one of the most commonly diagnosed illnesses (Klompas, 2023). Due to its common incidence CAP is the leading diagnosis in this case and would be confirmed with a chest xray.

2.      Tuberculosis (TB)- TB needs to be considered in this case due to the fact that the patient recently immigrated from a Latin American country and did not receive BCG vaccination ( Dunphy et al., 2019). This diagnosis also needs to be considered because when considering the worldwide population as a whole TB is the most common cause of hemoptysis ( O’Gurek & Choi, 2022). According to Wei et al. (2020) the incidence of TB in Columbia is 10-99 per 100,000 population per year. Factors that make the diagnosis of TB less likely in this case is that the patient is not immunocompromised with contributing diagnosis such as HIV or the use of immunosuppressive medications (Dunphy et al.,2019). Sputum gram stain and culture and chest xray would help to rule in or out this diagnosis.

3.      Influenza- Influenza is another diagnosis to consider because its classical presentation includes fever, chills, and nonproductive cough (Dunphy et al.,2019). A risk factor in this case is that the patient did not receive influenza vaccination (Dunphy et al.,2019). This was placed lower on the list of differentials due to the fact that the patient reports these symptoms have been going on for 2 weeks. Typically, in influenza the cough is present early in the course of illness. Also the fever typically lasts 3-5 days (Dunphy et al.,2019).

4.      Covid-19- Covid-19 needs to be included in the differential diagnosis because the patient has many of the symptoms classically identified in this illness such as fever, cough, sore throat, breathlessness, and fatigue (Singhal,2020). The fact that she has known exposure to other people who are acutely ill and lacks vaccination place her at risk for Covid-10 (Singhal,2020). Negative PCR testing will rule out the diagnosis (Pascarella et al.,2020).

Plan:

Primary Differential Diagnosis: Community acquired pneumonia (CAP)

Pharmacology

ibuprofen [Motrin, Advil] 400 to 600 mg PO every 6 to 8 hours as needed for sore throat, myalgias, or headache.

acetaminophen [Tylenol] 650 mg PO every 4 to 6 hours as needed for sore throat, myalgias, or headache.

guaifenesin 200 to 400 mg PO every 4 hours as needed for cough

Albuterol hfa 90 mcg inhaler 2 puffs every 4 hours as needed for sob

Augmentin 875 mg twice a day orally for 5 days

Azithromycin 500 mg orally  day 1, then 250 mg daily days 2-5

(Dunphy et al.,2019)

Non-Pharmacology

Advise the patient to rest. Drink plenty of fluids. Gargle with salt water to help alleviate the sore throat. Discuss appropriate hygiene including washing the hands frequently to avoid transmission to others and to avoid future infections (Dunphy et al, 2019).

Diagnostics:

Influenza PCR to rule out influenza. Covid-19 PCR to rule out Covid-19. Chest xray to confirm diagnosis of pneumonia and then in this case I would do follow up chest xray film in 4 weeks to check for resolution due to her increased lung cancer risk due to smoking and her report of hemoptysis ( Klompas,2023). CBC and CMP to evaluate for any signs of sepsis which may require hospitalization such as leukocytosis, abnormal renal, or liver function (Klompas, 2023). In this case there is a suspicion for TB so sputum culture with gram stain would be obtained to help rule this out (Dunphy et al.,2019).

Consults/Referrals

No Specialist referral is indicated at this time

Patient education: 1. The patient should receive the influenza vaccine annually. 2. The patient should receive the Prevnar13 pneumonia vaccine once she is feeling better and then one year later receive the pneumovax23. 3. She should be encouraged to be vaccinated against covid-19. 4. She needs to be counseled on smoking cessation 5. I would instruct the patient to get plenty of rest. 6. I would instruct the patient to drink plenty of fluids. 7. I would instruct the patient to use humidified air. 8. I would advise the patient to go to the emergency room with worsening symptoms, any difficulty breathing, or confusion 9. I would instruct the patient to take the antibiotic exactly as prescribed and finish the entire course even if feeling better 10. Use saline nasal spray to help with sore throat. 11. Use topical anesthetic spray for sore throat such as chloraseptic.

(Dunphy et al.,2019).

Follow up:

I would complete wellness check on patient in 48-72 hours to make sure symptoms were improving. I would advise the patient to seek care at the emergency room if shortness of breath or wheezing developed. I would advise the patient to schedule an office visit in 1 week to follow up on symptom resolution and then 4 weeks to review follow up xray films (Dunphy et al.,2019).

Health Maintenance: I would counsel the patient on the importance of smoking cessation. The patient should receive the influenza vaccine annually. The patient should receive the Prevnar13 pneumonia vaccine once she is feeling better and then one year later receive the pneumovax23.  She should be encouraged to be vaccinated against covid-19.

Social Determinants of Health: Due to the fact that all of the patients family members are undocumented residents of the united states it would be important to recognize that this population may face lack of culture competency when receiving healthcare ( Chang,2019). It would be important to make sure that there are translation services available so that the patient feels comfortable and is able to better share their story about their symptoms and so that they can understand the treatment plan. Written instructions on prescriptions should be offered in the patients preferred language. It would be important for the health care provider to realize that the patient may have concerns about disclosing their status due to fears of deportation. There may also be challenges related to lack of health insurance, poverty, housing insecurity, and food insecurity ( Chang,2019). I would inquire about these types of challenges and connect the patient with appropriate community resources to assist. It would also be important to consider the cost of medication and testing and base treatment decisions off of this.

References

Chang, C. D. (2019). Social determinants of health and health disparities among immigrants and their children. Current Problems in Pediatric and Adolescent Health Care, 49(1), 23–30. https://doi.org/10.1016/j.cppeds.2018.11.009

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th

            ed.). F. A. Davis Company.

Klompas, M. (2023). Clinical evaluation and diagnostic testing for community-acquired

pneumonia in adults. Uptodate. Retrieved January 21,2023, from https://www.uptodate.com/contents/clinical-evaluation-and-diagnostic-testing-for-community-acquired-pneumonia-in-adults

Méndez-Brich, M., Serra-Prat, M., Palomera, E., Vendrell, E., Morón, N., Boixeda, R., Cabré, M., & Almirall, J. (2019). Social Determinants of community-acquired pneumonia: Differences by age groups. Archivos De Bronconeumología, 55(8), 447–449. https://doi.org/10.1016/j.arbres.2018.12.012

O’Gurek, D., & Choi, H. Y. J. (2022). Hemoptysis: Evaluation and management. American Family Physician , 105(2), 144–151.

Pascarella, G., Strumia, A., Piliego, C., Bruno, F., Del Buono, R., Costa, F., Scarlata, S., & Agrò, F. E. (2020). COVID-19 diagnosis and management: a comprehensive review. Journal of internal medicine, 288(2), 192–206. https://doi.org/10.1111/joim.13091

Singhal T. (2020). A Review of Coronavirus Disease-2019 (COVID-19). Indian journal of pediatrics, 87(4), 281–286. https://doi.org/10.1007/s12098-020-03263-6

Wei, M., Yongjie Zhao, Zhuoyu Qian, Biao Yang, Xi, J., Wei, J., & Tang, B. (2020). Pneumonia caused by Mycobacterium tuberculosis. Microbes and infection, 22(6-7), 278–284. https://doi.org/10.1016/j.micinf.2020.05.020

Value: 100 points

Due: Create your initial post on Day 3, Initial Response post by Day 5, and Reflective Response by Day 7.

Gradebook Category: Simulated OV Discussions

Introduction

Prior to completing this first discussion forum, please watch the Discussion Board Directions video for more information on how to complete the forums.

Discussion Board Instructions (2:53 Minutes)

Discussion Board Instructions Video Transcript

Initial Post

Imagine that you are a primary care provider in the middle of your busy Thursday and your 2:00 p.m. appointment is as follows:

HPI: A 75-year-old patient of Hispanic descent arrives in an immigrant healthcare clinic with fever, chills, a sore throat, and a nonproductive cough. She speaks some English. The patient appears very ill, with dry mucous membranes, dark circles under the eyes, and pale skin. The patient appears anxious and is reluctant to make eye contact or speak. The health history reveals that the patient lives with extended family in a home setting, including infants and elderly. All of the family members are undocumented residents of the United States.

Past Medical History: Hypertension, Asthma.

Family History: Father (Deceased 81 / Stroke); Mother (Alive 95 / HTN, COPD, Diabetes)

Complete the following:

Initial Post by Wednesday (Day 3) at 11:59 p.m.

List 10–20 questions of subjective information that your patient will need to provide to help you formulate your differential diagnoses and plan. Include two scholarly references for the questions that you ask of your patient. See the Grading Rubric for more detail.

Initial Response Post by Friday (Day 5) 11:59 p.m. Choose a classmate’s questions to answer:

Every peer post should only have one response post. Please do not reply to a peer if a response is already posted.

You are answering as the patient. Make it case appropriate but imaginative. Be creative and answer thoroughly. No references are needed.

Reply Posts

Reflective Response Post by Sunday (Day 7). Please respond with the following:

Four appropriate differential diagnoses and rationales with references. For each differential diagnosis, explain why this is an appropriate differential and how it was/would be ruled in or out. Support your answers with references.

Pick one differential and create a plan of care for that patient.

Plans must include Pharmacology, Non-Pharmacology, Labs/Diagnostics, Referrals/Interprofessional Communications, Patient Education (10–15 individual items minimum) and follow up.

Make sure to pick one health maintenance item for this patient (primary or secondary) and explain to the patient why this is important.

Address one social determinant of the health this patient may face during your visit. How will you help the patient overcome this obstacle to health care?

Please refer to the Grading Rubric for details on how this activity will be graded.

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