CAP Case Study: 65-Year-Old Female With Pneumonia

Patient Presentation and Working Diagnosis

Chief Complaint: A three-day fever accompanied by a persistent cough.

The patient is a 65-year-old woman presenting with a complaint of persistent fever and cough. She stated that the illness began three days ago upon waking. At the onset, she reported a feverish feeling and the expulsion of yellowish-green phlegm during coughing fits. The symptoms have worsened over time. She also reported recurring pain in the right chest when taking a deep breath. The patient noted that her husband had been ill with similar but milder symptoms approximately one week prior.

Physical Examination
Vital Signs: BP 128/86, HR 101 (regular), RR 18, T 37.4°C
General: Slight increase in breathing rate; no discomfort expressed.

Working Diagnosis:

Community-acquired pneumonia (CAP)
Tobacco use disorder

Pathophysiology and Treatment Plan

Community-acquired pneumonia (CAP) is considered the most common type of pneumonia. In approximately 85% of CAP cases, the causative agent is one of three pathogens: Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. CAP is contracted by assimilating the pathogen through inhalation, after which it is transmitted through the respiratory system to a lung segment or lobe. The elderly and individuals with compromised immune systems bear a high risk of contracting CAP, with CAP's mortality rate being particularly elevated among such vulnerable populations (Cacciatore et al., 2017).

Treatment Plan:
The patient's low CURB-65 score led to the decision to treat her as an outpatient. The Pneumonia Severity Index (PSI) was not calculated, as no Arterial Blood Gases (ABGs) were available.

Pharmacologic Concepts:

Antibiotics are to be used for the patient's treatment for at least five days. Antibiotic treatment should not be stopped until the patient's fever has subsided and has not returned for at least 48 to 72 hours. The most widespread causative agents of CAP are S. pneumoniae, Mycoplasma pneumoniae, and H. influenzae. A change of treatment plan may be required if the patient's history, clinical findings, and epidemiology necessitate it.

Non-Pharmacologic Measures:

The patient should stay hydrated by drinking fluids, take deep breaths and cough hourly, and use a humidifier to moisten the air. The patient should also get plenty of rest. Acetaminophen, ibuprofen, or naproxen may be taken to relieve pain and fever.

SOAP Note

Education and Counseling:

The importance of completing the full antibiotic prescription is to be impressed upon the patient; antibiotic use should not cease even if symptoms disappear. The patient is instructed to report back if new symptoms develop or existing symptoms worsen — such as shortness of breath, increasing chest pain, or blood-tinged mucus. The patient is to have a repeat chest X-ray in six months to determine whether the pneumonia is associated with an underlying mass, given her history of smoking.

S (Subjective):
The patient is a 65-year-old female reporting fever and a persistent cough that causes the expulsion of yellowish-green sputum. She indicated that the symptoms appeared three days prior and have worsened since. She denied shortness of breath (SOB), palpitations, dyspnea on exertion (DOE), lightheadedness, nausea, vomiting, diarrhea, abdominal pain, and headaches. She reports right-sided chest pain when taking a deep breath. She is able to consume fluids without difficulty but suffers from a lack of appetite. The patient is a smoker, consuming one pack of cigarettes daily, and does not consume alcohol. She reports that her husband experienced similar but milder symptoms one week prior, which resolved without treatment. The patient has not used antibiotics in recent years. Her medical history is significant for arthritis and hypertension (HTN). She received an influenza vaccine earlier this year but has not received a pneumococcal vaccine.

O (Objective):
Vital Signs: T 37.4°C, BP 128/86, RR 18, HR 101 (regular), pulse oximetry 98%
General: Exhibits mild tachypnea; no discomfort reported.
Skin: Warm, dry, and firm.
HEENT: No sinus tenderness. PERRLA, EOMs intact. Normal fundoscopic exam. Tympanic membranes normal; slight reddening of the turbinates with no discharge. No pharyngeal exudate, cobblestoning, or enlargement.
Neck: Supple; no thyroid enlargement, jugular vein distension (JVD), or carotid bruits. No lymphadenopathy.
Cardiovascular: Regular rate and rhythm (RRR) without murmurs, rubs, or gallops.
Respiratory: No difficulty breathing; diminished breath sounds, dullness to percussion, and increased tactile fremitus in the right lower lobe (RLL). Mild crackles in the RLL without wheezes or egophony.
Abdomen: Soft, non-tender, with normal bowel sounds and no organomegaly.
Extremities: DP and PT pulses +2; trace pedal edema.
Mental Status: Awake and oriented ×3.

Labs: CBC — WBC 14,900; neutrophils 87%; platelets 310,000/µL; Hgb 16; Hct 48. BMP — Na 137; K 4.1; BUN 15; Cr 1.0; BG 148.
CXR: Consolidation of the right mid lobe. No pleural effusion noted.
CURB-65 Pneumonia Severity Score: 1 point (age) — low risk.

A (Assessment):
CAP: Clinically stable.
HTN: At JNC (Joint National Committee) 8 goals.
Tobacco use: Patient expresses no desire to quit.

P (Plan):
CAP: Azithromycin 500 mg daily × 3 days. The patient was counseled on the need to complete the full prescription even if symptoms resolve. She was advised to drink fluids, rest, take deep breaths and cough hourly, and use a humidifier. Acetaminophen may be used for fever or pain. A pneumococcal vaccine was administered today.