Case Study #2: Pneumonia
Place: Medical Ward
“Hi Tracie, I’m here to review a couple of patients for discharge.”
“Hi Dr. Hunicutt, I would also like to talk about Mrs. Erin Johns.”
“Oh the lady with pneumonia and COPD. She is doing better, yes?”
“Much better it seems, her C&S results are in along with the rest of her morning lab work. I have her assessment here to review. The RT has moved her to Optiflow again and Physio is seeing her daily, and ambulating her in the hallway starting today.”
“That sounds good. Big improvement. Ok, the discharges I will get to. Let’s look together at the C&S results.”
Dr. Hunicutt pulls up the lab results for Erin and immediately goes to the C&S.
“Ok Tracie, what antibiotic is Mrs. Johns on?”
“Excellent. That is the recommended coverage. Now let’s look at her C&S.”
On the computer screen, Tracie sees a list of about 10 antibiotics with either R or S beside each. For the antibiotics that Erin is on, she sees an S beside each one. “The antibiotics Mrs. Johns is on are appropriate for her as the bacteria is sensitive to them,” says Tracie.
“Correct,” states the doctor. “And since Mrs. Johns is doing well and you are mobilizing her, I would like to get rid of her IV to make that job easier.”
“How are you going to do that? I know azithromycin comes in PO form, but ceftriaxone is only IV.”
“Take a look at the list and see if there is another antibiotic that you recognize that can be given PO.”
“That’s correct, and since the two antibiotics are different classes and work slightly differently, we are cross-covering Mrs. Johns so she should continue to get better.”
“I think she will be happy to have the IV capped.”
“Most patients are. So I am going to write the orders for levofloxacin 750mg PO q 24 hours and azithromycin 250mg PO daily. Has she had her antibiotics today?”
“Yes. She should be just finishing now on the IV pump.”
“Great. I will state to start these with breakfast tomorrow. Now let’s go see her and then I’ll see the discharge patients and write their orders.”
Both Dr. Hunicutt and Tracie get up and move towards Erin’s room. As they get closer to the room they can hear the occasional bark. Coming into the room they see a small hairless dog sitting on Erin’s lap and Erin’s son sitting on the edge of the bed. Erin is playing tug of war with a face cloth and the dog.
Tracie looks at the whole scene and shakes her head, thinking, That is one ugly dog but wow, Mrs. Johns seems really happy today.
“Hi Mrs. Johns, do you remember me?”
Erin slowly looks up from her game of tug of war with Trixie to consider the man standing before her. “You are my doctor, I believe?”
“That is correct, at least for the time that you are in the hospital. I don’t have an office, but the whole hospital could be considered my office. Tracie and I have reviewed your chart and your treatment regimen and we will be making some adjustments to your IV. With your improvement and walking, it looks like we can cap your IV and start you on oral antibiotics.”
Erin looks at both of them. “I’ve had oral antibiotics before and they upset my stomach.”
“Well, if your stomach is not upset now with the IV antibiotics, I don’t expect you will be upset with the oral ones, because it’s the same medication. Let’s try it and see.”
“Oh, so I get rid of this?” Erin indicates the IV in her left arm.
Tracie, shakes her head. “Mrs. Johns, I will remove the tubing, but we will leave the rest in your arm in case something changes. I am sure you don’t want another IV started. I will wrap it up with a dressing, and it will be less bothersome without the tubing attached.”
Erin’s son looks up at Dr. Hunicutt. “When can she come home?”
“That’s a good question. I would like to do another chest X-ray today. Your mom needs a couple of more days of antibiotics and to be completely off any oxygen therapy for 24 hours. Once that is met, I would be pleased to see her go home with you.”
“How long will that be?”
“Oral antibiotics start tomorrow so the earliest for home would be three days from now maybe two if your mom tolerates no oxygen starting tomorrow. I don’t think we need to rush. She is getting great care here.”
“True, but I need some help at home too.”
“That may be, but your mom is pretty sick. When she goes home she will not be up to helping out very much and you will need to take care of her a bit longer.”
Thomas looks down at his feet and seems resigned to what Dr. Hunicutt says.
Dr. Hunicutt looks at both of them. “Any questions?”
When neither of them makes eye contact or speaks, the doctor adds, “All right then, I will order the chest X-ray and let Tracie cap off your IV. I will see you tomorrow.”
Dr. Hunicutt leaves.
Tracie goes outside and grabs supplies to cap off Erin’s IV. Just as she is finishing, Gladys comes in and says, “Ready for a walk Mrs. Johns?”
“No, but Trixie is. Can we take her?”
“Oh, we’re not going outside. Let’s just walk up and down the hall a bit. We need to build up your stamina.”
Thomas reaches out and picks up Trixie. “I’ll take her outside. I have to go to work anyway. Trixie is staying with the next door neighbors so she will be ok. I will see you tomorrow, mom.”
Gladys and Tracie reposition Erin and get her standing. Tracie follows behind with the oxygen tank as Gladys encourages Erin to walk.
Erin looks around the hallway as she leaves her room, and says, “I can’t believe I need two people to help me walk. This getting old really is not what I expected.”
“You are doing well. Let’s keep going.”
Tracie and Gladys navigate Erin to the lounge and back to her room. Just as they get her back, Glen, the X-ray porter comes in with a wheelchair. “Hey, it’s picture time. Ready to smile, Mrs. Johns?”
Erin looks up at Glen and thinks, He does look familiar. He is striking, maybe another doctor? She answers him, “I sort of remember you.”
Glen smiles “I am the lovely gentleman who will escort you to the Radiology Department. Gurpreet is awaiting your presence to take a picture.”
“Oh right, I remember you. You drive a wheelchair like a race car.”
Tracie and Glen laugh. Gladys helps Glen get Erin into the wheel chair. Glen hangs the oxygen tank on the back of the chair. “All right, let’s see if we can set a record to the department.”
“Oh, no—you take it slow, you whipper-snapper. I am just feeling fine and don’t need to crash into anything.”
“I’m a safe driver.” Glen maneuvers the wheelchair out into the hallway and to the elevators. They take the elevator to the second floor which opens directly facing the doors of the Radiology Department.
Glen pushes Erin in and around to X-ray Room 2. “Hey Gurpreet, Mrs. Johns is here.” Her chest X-ray is completed after which Glen wheels Erin to the elevator and back to the seventh floor.
Tracie sees Glen and Erin coming down the hallway and meets them in Erin’s room. Tracie helps Erin from the wheelchair to a chair at the bedside and covers her with a blanket. “Do you need anything right now?“
“No. I am a bit tired but should be good.”
Glen and Tracie leave Erin to herself.