Acute Pulmonary Plan of Care
Review the pulmonary infection cases to determine whether the diagnosis is infectious rhinitis, influenza, acute bronchitis, acute bronchiolitis, or pneumonia. Then, you will begin the plan of care.
J.M. is a 21-year-old male.
Subjective Data (condensed)
CC: "I feel awful. I couldn't go to class this morning."
HPI/ROS
Sudden onset of myalgia with his body aching all over and headache for the past day. He feels tired and has the chills, and his temperature was 100°F. He has a mild nonproductive cough. He denies rhinorrhea, sinus pain, nausea, otalgia, or shortness of breath. Denies nausea, abdominal pain, or vomiting. He reports exposure to sick contacts in his dorm, stating, "Everyone seems to be coughing and catching a cold or the flu."
Medications: none
Allergies: penicillin
Past medical history: healthy
Social history: college student, lives in a dormitory. Nonsmoker and drinks alcohol once a week, about two or three beers.
Objective Data
Physical exam:
Vital signs: temperature 100°F; pulse 98 beats per minute; respiratory rate 18 per minute; blood pressure (110)/(70) mmHg; pulse oximeter 98%
General: ill and tired appearance
Head, Eyes, Ears, Neck, Throat (HEENT): unremarkable
Neck: no lymphadenopathy; negative Kernig sign, negative Brudzinski sign
Cardiovascular, lungs, abdomen: unremarkable
1. What other subjective or objective data would you determine? (10 points)
2. What diagnostic tests (if any) would you advise for this client? Provide rationale. (10 points)
3. What is the most likely primary diagnosis (select one) and pathogen causing this disorder? (10 points) - Assessment
Discuss the data that supports your decision. (10 points)
