Appendices: Case study for Pneumonia
Place: Medical Unit
“Hi Tracie, I’m here to review a couple of patients for discharge.”
“Hi Dr. Hunicutt, I would also like to talk about Ms. Miki Huang.”
“Oh, the lady with pneumonia and COPD. She is doing better, yes?”
“Much better it seems, her C&S (culture and sensitivity) 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. Okay, the discharges I will get to. Let’s look together at the C&S results.”
Dr. Hunicutt pulls up the lab results for Miki and immediately goes to the C&S.
“Okay Tracie, what antibiotic is Ms. Huang on?”
Tracie pulls up the MAR. “She is on ceftriaxone 1 gram IV q 24 hours, and azithromycin 500mg IV q 24 hours.”
“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. R represents antibiotic resistant, while S stands for antibiotic sensitive. For the antibiotics that Miki is on, she sees an S beside each one. Tracie understands that this means the bacteria in her patient’s lungs are sensitive to ceftriaxone and azithromycin. “The antibiotics Ms. Huang is on are appropriate for her as the bacteria is sensitive to them,” says Tracie.
“Correct,” states the doctor. “And since Ms. Huang 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.”
Tracie considers the list again, thinking, “No, gentamycin is IV, cefotaxime is IV…Oh wait, here is levofloxacin. She speaks up, “Okay, Dr. Hunicutt, I think levofloxacin can be given PO.”
“That’s correct, and since the two antibiotics are different classes and work slightly differently, we are cross-covering Ms. Huang 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 just be 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 Miki’s room. As they get closer to the room, they can hear Linda and Miki talking quietly, and the occasional chuckle. Coming into the room, they see the mother and daughter duo sitting and chatting together.
Tracie observes and thinks to herself, “I guess it’s good for Miki to have at least one person she can speak to here. If I was her, I would want a daughter like Linda too.”
“Hi Ms. Huang, hi Linda, do you remember me?”
Miki and Linda both look up from their conversation and consider the man standing before them. “You’re my mom’s doctor, right?”
“That is correct, at least for the time that she is 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.”
Linda speaks up. “Oh, I think she’s had oral antibiotics before, and they upset her stomach.”
“Well, if her stomach is not upset now with the IV antibiotics, I don’t expect that it will be upset with the oral ones because it’s the same medication. Let’s try it and see.”
“Will you get rid of this then?” Linda indicates the IV in her mother’s left arm.
Tracie shakes her head. “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.”
Linda 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.”
“And 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, it’s just that I don’t want to miss more work than necessary, and I know that my mom feels a lot more comfortable at home too. Nothing in this environment feels like home for her, even the food and television.”
“That may be, but your mom is pretty sick.”
Linda looks down at her feet and seems resigned to what Dr. Hunicutt says. Dr. Hunicutt looks at the 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, and Linda drops into her chair, thoroughly exhausted.
“Linda, tell me what the doctor said,” Miki demands.
Linda drops her face into her hands. “Ugh, please Mom, just give me a second. My head is spinning.”
“Your job is to translate! You can’t even do that correctly, the least you could do is tell me what happened afterwards.”
Linda groans, “Mom, I will! Give me a break, you don’t know how it feels to be relied on 24/7 to translate everything.”
“And you have no idea how it feels to not know what people are talking about even though you’re the topic of discussion,” Miki replied reproachfully. “I would just like to know what is going to happen with me and when I can go home, is that too much to ask?”
Meanwhile, Tracie has gone outside and grabs supplies to cap off Miki’s IV. Just as she is finishing, Gladys comes in and says, “Ready for a walk, Ms. Huang?”
Linda cracks a smile and turns to her mom. “Mom, time for a walk.”
Miki shifts her position apprehensively. She hates exercising and is not ready to showcase her athletic abilities in front of all these doctors and nurses. “Linda,” she whispers urgently. “Tell them I’ll walk on my own at home.”
“What? No way, Mom,” Linda replies. “You have to start walking now so you can get better faster. The doctors know what they’re saying.”
The two glare at each other, and Gladys and Tracie reposition Miki to get her standing. Tracie follows behind with the oxygen tank as Gladys encourages Miki to walk, which she does reluctantly.
Miki looks around the hallway as she leaves the room, finding it unbelievable that she now needs two people to help her walk.
Tracie and Gladys navigate Miki 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!”
Miki smiles politely but groans inwardly. “Oh god, it’s the man who drives the wheelchair like a race car.”
Gladys helps Glen get Miki into the wheelchair. Glen hangs the oxygen tank on the back of the chair, and then 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 Miki in and around to X-ray Room 2. “Hey Gurpreet, Ms. Huang is here.” Her chest X-ray is completed, after which Glen wheels Miki to the elevator and back to the seventh floor.
Tracie sees Glen and Miki coming down the hallway and meets them in Miki’s room. Tracie helps Miki from the wheelchair to a chair at the bedside and covers her with a blanket. “Do you need anything else right now?”
Miki shuts her eyes, and Tracie looks uncertainly at Linda who smiles reassuringly. “Don’t worry, she should be good for now.”
Glen and Tracie leave the room.
Linda and Miki settle back into their chair and bed, and Linda decides to speak up. “Hey, Mom, I think the doctors are going to be thinking about letting you go home soon! What do you think?”
“Hmfph. I could have gone home ages ago if I wanted to.”
Linda sighs. “Mom, I know that you are aware of how sick you are so just stop pretending. I think even once we get home you will still need to recover. I already spoke to my manager and I’m going to be working 2 hours less each day so I can continue to take care of you; there is no room for discussion.”
“Don’t worry, I’m going to be a model patient until I get discharged. You said the doctors told you I have to be off oxygen for how long?”
“Just 24 hours! And then we can both go home and get on with our lives, won’t that be fun?”
Both women sit in silence for a moment, contemplating.
Miki spoke up hesitantly. “Linda…I know I don’t say this often, but I do appreciate everything you’ve done to take care of me. Not even just my time in the hospital, but in general. And I’m sorry for things I’ve said out of frustration.”
Linda scoffed, “No need to thank me Mom, there’s obviously nothing I want to see more than my mother being strong and healthy.” However, Linda was secretly touched and pleased that her mother truly recognized all the sacrifices she had made.
Miki reaches out to pat Linda’s hand, and the two of them continue to talk about their plans at home.
This section has been from Health Case Studies by Glynda Rees, Rob Kruger, and Janet Morrison.