You are on an Adult Acute Care (AAC) rotation and your preceptor has assigned the following patient for you to present. You should present the patient in the order that was reviewed. In preparing for your presentation, prepare to answer questions related to the patient’s disease state, medications (MOA, side effects, uses, contraindications, antidotes, etc.). Your resources should include disease state guidelines, AccessPharmacy, Lexicomp, Micromedex, and ClinicalKey.
Name: Judy Hunter-Johnson
ROS: JH is a good historian. She has been experiencing shortness of breath, a productive cough with rusty-brown colored sputum, subjective fevers, chills, and pleuritic chest pain that is “right in the middle of her chest.” She denied any hemoptysis as well as recent travel or sick contacts. She endorses some nausea/vomiting.
Gen: Caucasian female with moderate respiratory distress, appearing somewhat anxious and uncomfortable.
VS: HR 127 bpm BP 152/90 mm Hg RR 31 Tmax = 39.5 oC Height: 159 cm Weight: 53 kg
HEENT: PERRLA, EOMI, dry mucous membranes
Lungs: Tachypneic, labored breathing; coarse rhonchi right lung field, decreased breath sounds
CV: Tachycardic, with regular rate and rhythm
Na 142 meq/L
Cl 104 meq/L
BUN 27 mg/dL
Glucose 129 mg/dL
Hgb 12.2 g/dL
K 4.3 meq/L
HCO3 24 meq/L
sCr 1.1 mg/dL
WBC 22.3 × 103/mm3
AST 16 IU/L
ALT 34 IU/L
Chest X-Ray: Right middle and right lower lobe patchy infiltrates, likely pneumonia. Left lung is clear.
Respiratory culture: Pending Blood cultures ×2 sets: Pending
Streptococcus pneumoniae urine antigen: negative
Legionella pneumophila urine antigen: positive