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

Top 4 Differential Diagnoses:

Influenza: Influenza is likely the condition that this patient is presenting according to her symptoms. Influenza typically presents with symptoms such as a fever, sore throat, chills, fatigue, and a non-productive cough (Dolin, Hirsch, & Baron, 2022; Han et al., 2019). The patient’s age, location, presence of any co-morbid conditions, and sudden onset of symptoms typically present as either Influenza A or B, in addition to other symptoms like rhinorrhea, congestion, and myalgias (Dolin, Hirsch, & Baron, 2022; Han et al., 2019). This patient also did not receive a flu shot, which could precipitate this patient to likely have Influenza versus another type of infection (Dolin, Hirsch, & Baron, 2022; Han et al., 2019). Influenza testing through PCR or rapid is needed for a formal diagnosis (Dolin, Hirsch, & Baron, 2022; Han et al., 2019).

SARS-COV-2 (Coronavirus Disease 2019 (COVID-19)): COVID-19 is another diagnosis to rule out for this patient due to her symptoms of a fever, chills, myalgia, loss of taste and smell, and dyspnea (Serener & Serte, 2020). COVID-19 can also present with sudden onset of symptoms, like Influenza, and it is uncertain whether this patient has ever received a COVID-19 vaccination (Serener & Serte, 2020). Imaging is strongly needed to determine COVID-19 versus other types of pneumonia, testing through PCR (Serener & Serte, 2020). Sore throat is not a common presentation in patients with COVID-19 (only 5-10% of studied cases), leaving COVID-19 a more unlikely diagnosis (Curtis, 2022).

Community Acquired Pneumonia (CAP): CAP is likely another diagnosis that could be present in this patient. Many of the typical symptoms of CAP include a cough and fever, but it typically can present after another illness like Influenza; especially if it is viral in origin (Han et al., 2019). In a study by Han et al. (2019), there was a great chance that patients who had respiratory symptoms likely had Klebsiella Pneumoniae or Pseudomonas Aeruginosa. This diagnosis is also likely due to her age and co-morbid conditions, although it is uncertain she has it without confirming her receipt of a pneumonia vaccination and obtaining a more thorough assessment into her symptoms (Han et al., 2019). Also, a thorough history as to the onset, duration, and other symptoms would be important to obtain from this patient to be certain about a CAP diagnosis over an Influenza type diagnosis (Dains, Baumann, & Schiebel, 2018; Dunphy et al., 2020).

Tuberculosis (TB): Although less likely to occur, the patient will need to be ruled out for TB if more common illnesses are negative. Tuberculosis can present with respiratory symptoms, such as cough, chest pain fevers, fatigue, chills, and loss of appetite. The most distinguishing symptom is coughing up blood, which would be an important characteristic when diagnosing this patient (Mayo Clinic, 2023). Travel to Latin American countries is also a known risk factor to acquiring TB, so a thorough history of travel and family members who have been traveling recently is important information to collect (Mayo Clinic, 2023).

Plan:

Primary Differential Diagnosis: Influenza

Pharmacology

Some of the pharmacologic treatments for Influenza include Tamiflu (oseltamivir phosphate) within the first 48 hours of having symptoms, alternating between Tylenol 650mg PO Q4-6 hours as needed) and Ibuprofen (200-400mg PO daily as needed) to manage fevers and pain (Dolin, Hirsch, & Baron, 2022; Woo & Robinson, 2020).

Non-Pharmacology

Some of the non-pharmacologic treatments for Influenza include the use of a Nedipot steam to loosen secretions (Woo & Robinson, 2020); Nasal saline lavage (Woo & Robinson, 2020); Increasing hydration to manage her current symptoms of dehydration (Woo & Robinson, 2020); and using a humidifier to help moisten secretions (Woo & Robinson, 2020) could be helpful to this patient.

Labs/Diagnostics

Some of the labs that I would order include a Complete Blood Count (CBC) (a decreased PLT count is strongly associated with Influenza infection (Han et al., 2019)), an Influenza nasal PCR test to confirm the presence of Influenza A or B (Dolin, Hirsch, & Baron, 2022; Patel & Hwang, 2022), a chest X-ray if symptoms (upon further assessment) include shortness of breath (Dolin, Hirsch, & Baron, 2022; Serener & Serte, 2020), or, a chest CT and QuantiFERON Gold Test if the patient has presence of blood in the sputum (Mayo Clinic, 2023). These tests help rule out the other types of respiratory infections that this patient may be experiencing at this time.

Referrals/Interprofessional Communications

For Influenza, there are no referrals or interprofessional communications necessary, unless there is a severe case where hospitalization is needed (Dolin, Hirsch, & Baron, 2022; Han et al., 2019).

Patient education (10-15)

The patient should be educated on the following:

Follow up with your PCP if there is no improvement in 3-4 days (Woo & Robinson, 2020); Take all medication as prescribed (Woo & Robinson, 2020); Finish the entire course of antiviral treatment (e.g., Tamiflu)(Woo & Robinson, 2020); Use saline washes if there is presence of congestion (Woo & Robinson, 2020); When using nasal steams, take caution against sustaining a burn (Woo & Robinson, 2020); Follow up with consultations if recommended (Woo & Robinson, 2020); avoid cigarette smoke (Mayo Clinic, 2022), cover your mouth with your arm when symptomatic with coughing or sneezing (Woo & Robinson, 2020); monitor respiratory symptoms, especially with the history of Asthma (Woo & Robinson, 2020); and, if you have any worsening symptoms over the next week follow up with your doctor (Woo & Robinson, 2020). Ensure to have all vaccinations up to date, particularly the Influenza, COVID-19, and Pneumonia vaccines as soon as symptoms resolve (Woo & Robinson, 2020).

Follow up:

It would just be important to have the patient follow up with the PCP if the respiratory symptoms worsen, sudden shortness of breath occurs, or the patient is routinely not able to eat or drink at home (Dolin, Hirsch, & Baron, 2022; Woo & Robinson, 2020).

Health maintenance (primary prevention): Be sure to wash hands frequently to prevent the spread of Influenza to others, especially those who are elderly or are young children as having Influenza can be fatal (Mayo Clinic, 2023; Woo & Robinson, 2020). Avoid being in contact with those who are ill or engaging in high-risk settings to acquire an infection, such as a healthcare setting (Mayo Clinic, 2023; Woo & Robinson, 2020). Be sure to cover any coughs or sneezes with either a tissue or in the crux of the arm (Woo & Robinson, 2020).

Social determinants of health/how to overcome this obstacle to healthcare

Some of the social determinants of health for this patient would include the patient being undocumented, her inability to fully articulate her symptoms, and she is a known English Language Learner (Al Shamsi et al., 2020). These factors may cause barriers in the patient’s ability to disclose her symptoms, seek treatment, and pay for some of the services needed to be well (Al Shamsi et al., 2020). It can also negatively produce healthcare outcomes as disparities arise in those who are of a minority race (Al Shamsi et al., 2020). Therefore, it is important to have translation services assist this patient, reassure the patient about her undocumented status and her ability to freely speak about her healthcare needs, and that she receives the patient teaching she needs to prevent the spread of Influenza to others (Al Shamsi et al., 2020).

References

Al Shamsi, H., Almutairi, A. G., Al Mashrafi, S., & Al Kalbani, T. (2020). Implications of language barriers for healthcare: A systematic review. Oman Medical Journal, 35(2), e122. https://doi.org/10.5001/omj.2020.40

Curtis, B. (2022). Is my sore throat COVID-19 or not. OSF Healthcare. https://www.osfhealthcare.org/blog/is-my-sore-throat-covid-19-or-not/#:~:text=But%2C%20Dr.%20Curtis%20said%2C,and%20smell%20and%20difficulty%20breathing.%E2%80%9D

Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Dolin, R., Hirsch, M. S., & Baron, E. L. (2022). Seasonal influenza in adults: Clinical manifestations and diagnosis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/seasonal-influenza-in-adults-clinical-manifestations-and-diagnosis?search=influenza&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3

Dunphy, L. M. (2019). Primary care: Art and science of advanced practice nursing- An interprofessional approach (5th ed.). F. A. Davis.

Han, L., Ran, J., Mak, Y. W., Suen, L. K. P., Lee, P. H., Peiris, J. S. M., & Yang, L. (2019). Smoking and influenza-associated morbidity and mortality: a systematic review and meta-analysis. Epidemiology, 30(3), 405-417. DOI: 10.1097/EDE.0000000000000984

Keilman, L. J. (2019). Seasonal influenza (flu). Nursing Clinics, 54(2), 227-243. DOI:10.1016/j.cnur.2019.02.009

Mayo Clinic. (2023). Tuberculosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250

Patel, Z., & Hwang, P. (2022). Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis. UpToDate. https://www.medilib.ir/uptodate/show/6871

Serener, A., & Serte, S. (2020, November). Deep learning to distinguish covid-19 from other lung infections, pleural diseases, and lung tumors. In: 2020 Medical Technologies Congress (TIPTEKNO) (pp. 1-4). IEEE.

Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). F.A. Davis.

Sample Answer 2 for NU-664B Week 3 Discussion 1: Hispanic / Nondocumented Patient with Acute Illness

Four differential diagnoses:
1. Influenza.

Influenza (flu) is an acute respiratory virus that is caused by influenza A or B (Dolin, 2022). This is considered as a possible diagnosis because of the symptoms of fever, nonproductive cough, and myalgias (Dolin, 2022). Other symptoms that are common are sore throat and headache (Dolin, 2022). I would swab to rule this one out, but it can be ruled out since the patients illness has been going on for the past month. Flu typically lasts anywhere from 5-7 days.

2. Bacterial Pneumonia.

Bacterial pneumonia is the lead diagnosis because of the symptoms she is describing. She has had a cough for almost a month, that is very congested but nonproductive. There is a presence of chest pain, especially when coughing. Other symptoms common in a pneumonia presentation are sudden onset of fever, fatigue, chills, and myalgia (Dunphy et al., 2019). This patient is 75 years old, so if she does have pneumonia she could have mental confusion and increased weakness.

3. COVID-19.
   COVID-19 is the respiratory disease caused by SARS-CoV-2. This diagnosis should be considered because of the severity of symptoms. Shortness of breath is not typically present in flu. Along with her symptoms (sore throat, headache, fever, chills, myalgia, chest pain, SOB, non-productive cough), she is at high risk for severe disease due to her advanced age and chronic medical condition (asthma) (Cohen & Gebo, 2022). COVID-19 can be ruled out or confirmed with a SARS-CoV-2 PCR nasal swab. When dyspnea and increasing chest discomfort/tightness are experienced, those symptoms are indicative of pulmonary involvement (Cohen & Gebo, 2022).
4. Sepsis.

This is a must not miss diagnosis. She has had a cough and has felt unwell for about a month. Her body temperature in office in 102, she has lost a significant amount of weight from not eating, and is only voiding a few times a day. Because she is so ill-appearing, I would want to get labs for a septic work up. Labs would include CBC, CMP, serum lactate, and blood cultures (Neviere, 2022). Then giving an IM dose of ceftriaxone 1G in office. A broad-spectrum antibiotic like ceftriaxone has the potential to cover many bacteria and can jump-start eradicating the infection if it has gone to her blood. Blood cultures would take a couple of days, but the rest of the lab work would be returned quickly. Depending on the results, she may need to be admitted to the hospital for IV antibiotics and fluid resuscitation. In the outpatient setting, adults with comorbidities and no recent antibiotic use should be prescribed a cephalosporin and a macrolide, or Augmentin and doxycycline (Hollier, 2021).
Diagnosis: Bacterial Pneumonia

 

Pharmacology:

Ceftriaxone 1gram IM. Ceftriaxone 1gm given IM, STAT once.

Azithromycin- Take 2 (500mg) tablets by mouth on day 1, then take 1 (250mg) tablet once daily for 4 days.

Ibuprofen 200mg tablets. Take 2-3 tablets (400-600mg) by mouth every 6-8 hours for pain and fever control.

Acetaminophen 325mg tablets. Take 1-2 tablets (650mg) by mouth every 4-6 hours for body aches and fever control. Do not exceed 4000mg daily.

Ventolin HFA 17-g cannister. 200 actuations. Use 2 puffs every 4-6 hours for bronchospasm, or 1 puff every 4-6 hours during acute illness. Shake well before use.

Benzonatate 100mg gel capsules. Take 1-2 capsules (100-200mg) by mouth 3 times a day for cough.

 

Non-Pharmacology:

-increase fluid intake 1-2L per day
-rest, but be sure to move around several times a day
-sleep with cool-mist humidifier

Labs/Diagnostics:
-Chest xray
-CBC, CMP, Lactic Acid, and 2 sets of blood cultures.
-SARS-CoV-2 PCR Nasal swab (Cohen & Gebo, 2022).
-Influenza antigen nasal swab (Dolin, 2022).

Referrals/Interprofessional Communications: No referrals are needed for this patient at this time.

 

Patient Education:

-Increase your intake fluids. Water is best, but hydration is your goal. Drink something with electrolytes like Gatorade.
-Reduce your activity until your symptoms start improving.
-Alternate Ibuprofen and Acetaminophen every 3 hours. Example: Take ibuprofen @3pm and acetaminophen @ 6pm. Alternating the medications will help with body aches, chest pain, and better control fevers.
-Azithromycin is only a 5-day course but continues working for 10 days. This is why follow-up will be in one week if you are not improving. Avoid aluminum or magnesium containing antacids, this can reduce the effectiveness of the antibiotic. Take the WHOLE course of antibiotics even if your symptoms improve in 2-3 days. Not taking the whole course can lead to recurrent infection and antibiotic resistance.
-the Benzonatate is a cough suppressant medication. These will be most beneficial at night when trying to sleep.
-Ventolin is likely similar to the rescue inhaler you had back in Honduras. It is to be used for duration of your symptoms to help reduce dyspnea and cough. This medication can cause an increased heart rate, and this is normal. Make sure you shake well before each use (Hollier, 2021).

Follow-up: Follow-up in one week if you are not better. You may need different antibiotics. We will call you if the blood cultures show that you need a different antibiotic to treat the pneumonia. You should start to feel improvement of your symptoms in 48-72 hours. If your symptoms worsen, you have troubles breathing, increased chest pain, mental confusion, or fever not controlled by fever-reducing medications, you should go to the nearest ER. I would like to see you back in 4-6 weeks for a chest x-ray to ensure the infection is completely gone (Hollier, 2021).

Health maintenance item: COVID-19 and pneumococcal pneumonia vaccine.60-7
These are important in preventing more severe disease and hopefully prevent hospitalization. Getting these vaccines will also help protect your loved ones living with you. You have a higher risk of suffering from more severe complications following catching a virus because of your history of asthma (Dunphy et al., 2019).

References

Cohen, P., & Gebo, K. (2022). COVID-19: Evaluation of adults with acute illness in the outpatient setting. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/covid-19-evaluation-of-adults-with-acute-illness-in-the-outpatient-setting?search=COVID&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H499088308

Dolin, R. (2022). Seasonal influenza in adults: Clinical manifestations and diagnosis. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/seasonal-influenza-in-adults-clinical-manifestations-and-diagnosis?search=influenza&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: The Art and Science of Advanced Practice Nursing- An Interprofessional Approach. (5th ed.). F. A. Davis Company.

Hollier, A. (2021). Clinical Guidelines in Primary Care. (4th ed.). Advanced Practice Education Associates.

Lexicomp. (1978-2023). Benzonatate: Drug information. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/benzonatate-drug-information?search=tessalon%20perles%20adult&source=panel_search_result&selectedTitle=1~7&usage_type=panel&kp_tab=drug_general&display_rank=1#F140001

Neviere, R. (2022). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/sepsis-syndromes-in-adults-epidemiology-definitions-clinical-presentation-diagnosis-and-prognosis?search=sepsis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H21