ADMITTING HISTORY Ms Baker is a 28-year-old white woman who was 40 weeks pregnant and was scheduled for an emergency C-section on 06/06/2011. Ms Baker was released from the hospital 48 hours later with her baby girl. On 06/10/2011, Ms Baker visited the ER complaining of SOB, a productive cough with yellowish sputum, and a fever of 101.6. Ms Baker also stated that she has been having chest pain for three months now. She also said she has had pneumonia 3 times in the past 3-4 years. Ms Baker has no history of COPD but has been smoking one pack a day since she was 16 years old. (12 year pack history). Ms Baker admits to having multiple sex partners and was diagnosed with HIV during her pregnancy.
PHYSICAL EXAM
Pt appears to have shortness of breath. Patient appears malnourished despite just having a baby. She has a productive cough. Her sputum is green/yellow. Her HR is 98. RR is 24 and labored. Her BP is 122/84. Her Temp is 38.3 C (101 F).Pt has good air movement throughout all lobes. Pt has RML expiratory wheezing and fine inspiratory crackles her in the LLL, LUL, and RLL. Pt appears to have whitish plaques on her tongue. Pts chest rise is equal with dull percussion sounds over the LLL, LUL, and RLL. Pt has regular heart sounds with no murmurs or gallops. Pt is warm to the touch. No present edema. Pt complains that it is harder to breathe while laying flat. Pts SpO2 on room air was 89%. ABG results are pH - 7.45, PaCO2 - 31mmHg, PaO2 - 69mmHg, HCO3- -21mEg/L on room air. Pts chest x-ray showed an infiltration in the RML and in the right and left bases. The lab results are WBC - 3200. CD4 - 175. Lymphocytes - 280. Sputum C&S found Pneumocystis jaroveci.
SOAP:
S- Patient's CC is shortness of breath and a productive cough. Patient states sputum is a yellow tint.
O- Vitals are as follows... Hr- 98 with no arrhythmias or murmurs, RR- 24 and labored, BP- 122/84, Temp- 38.3 C. Fine inspiratory crackles are present in the LLL, LUL, and RLL. Faint expiratory wheeze is present in the RML. Chest rise is equal. Airflow is normal throughout all lung zones. No edema is noted. Sp02 is 89% on room air and ABG results are; pH- 7.45, PaCo2- 31 mmHg, Pa02- 69 mmHg, HCo3- 21mEg/L. Lab results show WBC count of 3200, CD4- 175, Lymphocytes- 280. Sputum cultures found Pneumocystis jaroveci. Whitish plaques are present on tongue.
A- Patient has an increased Work of breathing and mild hypoxemia, (Vitals, ABGs). The patient has a temperature and Xray shows diffuse infiltrates suggesting infection or atelectasis, sputum sample confirms strain of P. jaroveci. (Lung assessment, CXRay, sputum culture). Whitish plaques on tongue indicate an oral infection of Candida Albicans. (General assessment). Chronic respiratory alkalosis with mild hypoxemia. (ABGs- Compensated Respiratory alkalosis with mild hypoxemia). Patient has progressed from HIV to AIDS. (Lab results of CD4 count, Sputum culture positive for P. Jaroveci).
P- Incentive spirometry to treat or prevent possible atelectasis. Oxygen therapy per protocol to treat hypoxemia, keep sat above 92%. Reevaluate within 1 hour with follow- up CXR and ABGs. Suggest starting Sulfa antibiotics for P. Jaroveci infection. Follow up with CBC. Suggest antifungal treatment for Candida Albicans infection.
QUESTIONS:
1.) A mild immunocompromise patient's chest x-rays can look similar to a patient with what other disease?
2.) What is another infection, other that Pneumocystis jaroveci, which is associated with patients that have AIDS?
3.) What is Empiric Therapy and why is it used with AIDS patients?
4) What kind of treatment could the patient take at home to prevent recurrent opportunistic infections?
Pneumonia
ADMITTING HISTORYMs Baker is a 28-year-old white woman who was 40 weeks pregnant and was scheduled for an emergency C-section on 06/06/2011. Ms Baker was released from the hospital 48 hours later with her baby girl. On 06/10/2011, Ms Baker visited the ER complaining of SOB, a productive cough with yellowish sputum, and a fever of 101.6. Ms Baker also stated that she has been having chest pain for three months now. She also said she has had pneumonia 3 times in the past 3-4 years. Ms Baker has no history of COPD but has been smoking one pack a day since she was 16 years old. (12 year pack history). Ms Baker admits to having multiple sex partners and was diagnosed with HIV during her pregnancy.
PHYSICAL EXAMPt appears to have shortness of breath. Patient appears malnourished despite just having a baby. She has a productive cough. Her sputum is green/yellow. Her HR is 98. RR is 24 and labored. Her BP is 122/84. Her Temp is 38.3 C (101 F).Pt has good air movement throughout all lobes. Pt has RML expiratory wheezing and fine inspiratory crackles her in the LLL, LUL, and RLL. Pt appears to have whitish plaques on her tongue. Pts chest rise is equal with dull percussion sounds over the LLL, LUL, and RLL. Pt has regular heart sounds with no murmurs or gallops. Pt is warm to the touch. No present edema. Pt complains that it is harder to breathe while laying flat. Pts SpO2 on room air was 89%. ABG results are pH - 7.45, PaCO2 - 31mmHg, PaO2 - 69mmHg, HCO3- -21mEg/L on room air. Pts chest x-ray showed an infiltration in the RML and in the right and left bases. The lab results are WBC - 3200. CD4 - 175. Lymphocytes - 280. Sputum C&S found Pneumocystis jaroveci.
SOAP:
S- Patient's CC is shortness of breath and a productive cough. Patient states sputum is a yellow tint.
O- Vitals are as follows... Hr- 98 with no arrhythmias or murmurs, RR- 24 and labored, BP- 122/84, Temp- 38.3 C. Fine inspiratory crackles are present in the LLL, LUL, and RLL. Faint expiratory wheeze is present in the RML. Chest rise is equal. Airflow is normal throughout all lung zones. No edema is noted. Sp02 is 89% on room air and ABG results are; pH- 7.45, PaCo2- 31 mmHg, Pa02- 69 mmHg, HCo3- 21mEg/L. Lab results show WBC count of 3200, CD4- 175, Lymphocytes- 280. Sputum cultures found Pneumocystis jaroveci. Whitish plaques are present on tongue.
A- Patient has an increased Work of breathing and mild hypoxemia, (Vitals, ABGs). The patient has a temperature and Xray shows diffuse infiltrates suggesting infection or atelectasis, sputum sample confirms strain of P. jaroveci. (Lung assessment, CXRay, sputum culture). Whitish plaques on tongue indicate an oral infection of Candida Albicans. (General assessment). Chronic respiratory alkalosis with mild hypoxemia. (ABGs- Compensated Respiratory alkalosis with mild hypoxemia). Patient has progressed from HIV to AIDS. (Lab results of CD4 count, Sputum culture positive for P. Jaroveci).
P- Incentive spirometry to treat or prevent possible atelectasis. Oxygen therapy per protocol to treat hypoxemia, keep sat above 92%. Reevaluate within 1 hour with follow- up CXR and ABGs. Suggest starting Sulfa antibiotics for P. Jaroveci infection. Follow up with CBC. Suggest antifungal treatment for Candida Albicans infection.
QUESTIONS:
1.) A mild immunocompromise patient's chest x-rays can look similar to a patient with what other disease?2.) What is another infection, other that Pneumocystis jaroveci, which is associated with patients that have AIDS?
3.) What is Empiric Therapy and why is it used with AIDS patients?
4) What kind of treatment could the patient take at home to prevent recurrent opportunistic infections?