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Feb 20, 2024
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Patient History Analysis
After thoroughly reviewing Sally Pire's medical record, it is noted that she is a 60-year-old single
white female who works as a nurse's aide. Sally presented to her doctor's office with several upper respiratory symptoms, including cough, chills, fever, and sweat. She reported being a moderate smoker, and her past medical history includes several medical conditions, such as arteriosclerotic cardiovascular disease, alcoholism, hypokalemia, and gastritis. It is also noted that Sally has an allergy to aspirin. Sally has been hospitalized twice in the past few years. The first time was due to abnormal liver function tests evaluated at another facility. The second hospitalization was due to a fractured wrist, which is suspected to be caused by intoxication. It is important to note that Sally's family history shows a prevalence of alcoholism and cardiovascular disease, which can be risk factors for her current medical issues.
It is imperative that Sally receives proper medical attention for her current symptoms and that her medical history is considered when making decisions about her care.
Past Diagnosis
Her past diagnoses are arteriosclerotic cardiovascular disease (also known as atherosclerosis), hypokalemia, and gastritis.
Arteriosclerotic cardiovascular disease, commonly called atherosclerosis, is a pathological condition characterized by the accumulation of lipids, cholesterol, and other substances on arterial walls. This phenomenon triggers arterial stenosis and sclerosis, which impede the adequate flow of blood throughout the body. The most frequently employed diagnostic methods
for this disease include angiography, blood tests, computed tomography (CT) or magnetic resonance imaging (MRI), electrocardiography (EKG), and stress testing.
Hypokalemia is a medical condition characterized by low potassium levels in the blood. Potassium is essential in various bodily functions, including muscle and nerve function, heart health, and fluid
balance. The body's lack of potassium can lead to multiple symptoms, including weakness, fatigue,
cramping, constipation, and irregular heartbeat.
Hypokalemia can occur for various reasons, such as inadequate dietary potassium intake, excessive
potassium loss due to vomiting, diarrhea, excessive sweating, or underlying medical conditions like Cushing's syndrome. To diagnose hypokalemia, doctors may conduct a physical examination, blood tests to measure potassium levels, a 12-lead EKG to check heart activity, and an arterial blood gas (ABG) test to assess the body's acid-base balance.
Gastritis is a medical condition that involves inflammation of the stomach lining. It can occur due to various reasons, such as bacterial infections, excessive alcohol consumption, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), or other underlying medical conditions. Symptoms of gastritis can range from mild discomfort to severe abdominal pain, nausea, vomiting,
and loss of appetite.
To diagnose gastritis, doctors may conduct various tests, depending on the suspected cause of the condition. Standard tests include an upper gastrointestinal (GI) tract X-ray, esophagogastroduodenoscopy (EGD) to examine the stomach lining and take tissue samples, serum H. pylori antibody levels test to detect bacterial infections, H. pylori breath test to measure the presence of bacteria in the stomach, complete blood count, and stool analysis to check for blood in the stool or signs of infection.
It is essential to seek medical attention if you experience any symptoms of hypokalemia or gastritis
to receive prompt diagnosis and treatment.
Symptoms
Ms. Pire presented herself to the doctor's office with an upper respiratory tract infection characterized by cough, chills, fever of 102F, and sweating. An X-ray scan of her chest was ordered, which resulted in the detection of acute pneumonia. Due to her medical history, which revealed cardiac issues, smoking habits, and exposure to environmental conditions attributed to her age and job, she was considered at a higher risk of pneumonia. Consequently, an X-ray scan was ordered to confirm the presence of the disease. Following her admission to the hospital, additional tests were ordered, including urinalysis, complete blood count (CBC), sputum culture, and an electrocardiogram (EKG).
Alternate Symptoms
An alternative diagnosis to pneumonia, which presents with similar symptoms, could have been acute bronchitis. This respiratory disease is characterized by inflammation of the lining of the lungs and is often associated with upper respiratory tract infections caused by viruses. The specific cause of this inflammation is typically unknown, but bacterial infections, inhalation of irritants such as smoke or chemicals, and allergic reactions are less frequent causes. The elderly, young children and smokers are at higher risk of developing bronchitis. Given that the patient was a smoker, bronchitis could have been considered as a possible alternative diagnosis. (Story, 2020, p. 182).
Pathophysiology
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Pneumonia is a respiratory disease characterized by inflammation and fluid buildup in the lungs. The disease is caused by bacterial, viral, and fungal infections, with Streptococcus pneumoniae being the most common bacterial cause. The condition impairs breathing and limits oxygen intake, leading to severe health complications (American Lung Association, 2020).
The severity of the disease is influenced by several factors, including the pathogen causing the infection, the patient's age, and their medical history. Individuals who are immunocompromised, aspirate bodily fluids such as stomach acid or are exposed to viruses and bacteria are at higher risk of developing pneumonia. Additionally, pathogens can invade the lungs from the bloodstream or surrounding tissue, leading to pneumonia (Story, 2020, pg. 183).
Effective management of pneumonia requires accurate diagnosis, prompt treatment, and diligent follow-up. Clinicians should consider the patient's symptoms, clinical history, and risk factors when diagnosing and treating pneumonia. They should also carefully monitor and evaluate the patient's response to treatment to ensure a full recovery.
Past prescribed medications
Lanoxin is a cardiac glycoside medication that is typically prescribed for the treatment of heart failure. Its mechanism of action involves regulating sodium and calcium levels in the heart muscle cells, resulting in a slower yet more effective heartbeat. Turley (2021, p. 190) reported that this medication class has proven to be efficacious in treating heart failure patients.
Lasix is a loop diuretic drug, also known as "water pills." Loop diuretics are typically prescribed to patients with congestive heart failure, liver disease, or kidney disorders to
prevent edema or swelling. It stops the body from absorbing too much salt and, instead, allows it to be flushed out through the urine (Rx List, 2022).
Klotrix is a potassium chloride (KCl) drug. "Potassium chloride drugs are frequently prescribed for patients who are also on a loop diuretic or a thiazide diuretic drug to avoid potassium loss" (Turley, 2021, pg. 541). Maintaining an abnormal potassium level in the blood helps the body work properly. Most people get enough potassium through their diet; however, certain conditions may lower the body's potassium level; this includes diarrhea and vomiting, hormone problems, and treatment with "water pills"/diuretics (WebMD, n.d.).
Symptoms and Signs
On June 30th of YYYY, Ms. Pire presented to her physician's office with a recent onset of
respiratory symptoms, including shortness of breath, cough, fever, chills, and sweating. Despite attempting to continue with her daily activities, her symptoms persisted, prompting her visit. Upon examination, her physician noted a fever of 102°F and ordered a chest X-ray. The X-ray revealed an area in her lungs that was indicative of pneumonia. Considering these findings, her physician recommended hospital admission for further evaluation and treatment.
Misdiagnosis
Ms. Pire's current diagnosis of pneumonia is related to her previous chronic diagnoses of alcoholism, cardiovascular disease, hypokalemia, and gastritis. Due to her high-risk category, she needs careful monitoring. Her lab work shows that her potassium level is below normal limits, but it's possible that a pneumonia infection could be causing the drop. She must follow up with her doctor after discharge to determine her potassium
levels. Her elevated pulse could also be due to pneumonia, so she needs to check with her
doctor whether her heart rate has normalized once she feels better.
Treatments
Ms. Pire is currently receiving treatment for bacterial pneumonia based on her presenting symptoms. Diagnostic tests such as a chest X-ray, sputum culture and sensitivity test, complete blood count, urinalysis, electrocardiogram, SCG II, and electrolytes were performed to confirm the diagnosis. The sputum culture confirmed the presence of bacterial pneumonia.
Upon admission, Dr. Black prescribed Ampicillin, intermittent favorable pressure breathing treatments, and Aspirin in addition to the patient's current medications, which included Lanoxin, Lasix, and Klotrix. Throughout her stay, the medical team replaced Aspirin with Tylenol, likely due to the patient's allergy to Aspirin. Additionally, Dalmane was added to aid with sleep, Ampicillin was substituted with Erythromycin, and Dimetapp extents were administered. Afrin nasal spray was also added to the patient's treatment regimen.
The medical team carefully monitored Ms. Pire's condition throughout her stay, making appropriate adjustments to her treatment plan. The patient received attentive and professional care from the medical staff, resulting in a successful recovery from bacterial pneumonia.
Ampicillin and Erythromycin represent two effective antibiotics that have proved helpful in targeting the bacteria that cause pneumonia. It is a common practice among medical practitioners
to initiate therapy with one antibiotic and then transition to an alternative agent if the patient's symptoms remain unresponsive. This switch typically occurs midway through the course of treatment. Therefore, clinicians must exercise caution in selecting the most appropriate antibiotic
for the patient, weighing the benefits and drawbacks of each therapy.
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Intermittent favorable pressure breathing treatments (IPPBT) are therapies a physiotherapist provides. It involves providing the patient with a controlled pressure of gas to help their lungs open. This treatment is particularly effective in patients with respiratory issues, as noted by Handelsman in 1991. For the patient's current diagnosis of pneumonia, this treatment would be appropriate to help open her lungs.
Tylenol and Aspirin were appropriately prescribed to reduce any fever or pain that she was experiencing. However, in Ms. Pire's case, Aspirin should not have been prescribed, as it is documented in her chart that she is allergic to it, and she could have had a severe reaction to it.
It seems that Dalmane's prescription is not appropriate. This medication is typically used to treat insomnia (according to WebMD in 2021). Furthermore, there was no indication or complaint from the patient regarding their inability to sleep. Based on the nurse's report, the patient could sleep soundly throughout their stay.
Dimetapp Extents is an over-the-counter medication used to treat upper respiratory symptoms caused by colds and flu. Although it would have been appropriate for the current diagnosis, it's important to note that the Food and Drug Administration (FDA) discontinued its production in 2011 due to mislabeling, as mentioned in the Federal Register. Therefore, this medication is not recommended.
Afrin nasal spray is a medication that is prescribed appropriately for reducing swelling in the nose and sinuses. It helps with sinus congestion and clears the sinuses, which can help Ms. Pire breathe better. According to WebMD, this medication is effective in reducing nasal swelling and helps provide relief from sinus congestion.
Inaccuracies
Upon reviewing Ms. Pire's medical record, I have identified several inaccuracies that require attention. Firstly, an error was found in the Patient's History section. It was noted that Ms. Pire was allergic to Aspirin. Still, Dr. Black's orders for her admission date contradict this, as Aspirin of 650 milligrams every four hours for her elevated temperature was prescribed. Secondly, the discharge summary contained a discrepancy. The summary indicated that "...Ampicillin was stopped, and she was switched to Enalapril 500 milligrams, four times a day." However, the Doctor's Orders for 7/3/YYYY stated to "Discontinue Ampicillin. Erythromycin 500 milligrams every six hours for five days." Lastly, another inaccuracy was detected in the Discharge Summary. It was stated that "...Abdominal x-ray showed pneumonia, and I felt that she should be
admitted for further evaluation and treatment." However, it is essential to note that an abdominal X-ray cannot detect lung issues, and the appropriate diagnostic test for this would be a chest X-
ray.
It is imperative to note that if Ms. Pire had been allergic to Aspirin, it should have been avoided to prevent any adverse reactions. Allergic reactions to Aspirin may range from mild symptoms, such as hives, runny nose, and shortness of breath, to severe reactions like anaphylaxis, which can even be fatal (Li, M.D., Ph.D., 2022). Considering that Dr. Black knew about Ms. Pire's Aspirin allergy, it should not have been prescribed for her.
It is crucial to exercise due diligence when prescribing medications to patients, particularly those
with known allergies. In such cases, it is recommended that alternative medications be explored to avoid the risk of potential adverse reactions.
The inappropriate medication name in the discharge summary may have had severe implications.
Enalapril, a medication utilized to manage hypertension and congestive heart failure, was prescribed. The patient's clinical records indicate that she did not have congestive heart failure, and her blood pressure was within the standard range during her hospitalization. Therefore, Enalapril was not a necessary treatment. The medication error may have resulted in harmful consequences if the patient received an incorrect medication, such as Enalapril, instead of erythromycin, an antibiotic prescribed to continue treating her pneumonia.
The ultimate version of the discharge summary has been found to contain an error in that it indicates the doctor ordered an abdominal X-ray. This is an erroneous statement, as the lungs are located within the chest cavity, which houses the crucial organs of the respiratory system, including the heart and lungs. An abdominal X-ray of Ms. Pires would have been inadequate for capturing an image of her lungs. The abdomen consists of the digestive organs, including the stomach, large and small intestines, liver, gallbladder, and rectum, as stated by the BD Editors (2019).
If these issues had not been detected, they could have resulted in significant complications concerning the coding and billing system. The erroneous inclusion of a medication in the patient's chart would have led to confusion and denial from the insurance company. This error would have been due to the medication not being recommended for the patient's condition. Furthermore, such an error could have confused the medical team, ultimately leading to the administration of the incorrect medication. This could have resulted in adverse health outcomes for the patient.
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Similarly, listing an x-ray order for the wrong body part would have been denied by the insurance company. The patient was being treated for pneumonia, and having an x-ray of the abdomen to rule out pneumonia would have triggered an insurance denial. While such issues could have been resolved later, they would have portrayed the facility negatively. The facility would have appeared to have billed the insurance company incorrectly for the wrong medication or an improper x-ray. In summary, detecting these issues promptly was critical in avoiding significant problems with the coding and billing system. Ensuring that the patient received the correct medication and that the insurance company was charged appropriately was imperative.
An aspirin allergy in a patient's medical record necessitates a cautious approach to avoid any negative health consequences. Despite the patient's record indicating such an allergy, the doctor has prescribed the medication to treat a fever. The severity of the patient's allergy is not specified
in the available medical documentation. However, it is strongly advised that this medication should not be administered to the patient, even with a mild reaction. The fact that the medication is listed in the patient's medical record suggests that the provider may not have completed a full review of the patient's medical history, including their allergies. This oversight could have potentially life-threatening repercussions if the patient were to receive the medication and experience a severe anaphylactic response as a result. Addressing these issues is paramount to safeguard the patient's health and well-being.
To address the issue of inaccurate patient records, it is recommended that the ordering physician be involved in reviewing the documents to ascertain if they were aware of any mistakes. If the doctor agrees that there were genuine mistakes, appropriate actions can be taken to prevent such
occurrences. One such action could be implementing a probationary period, during which all records completed by the physician are closely monitored for accuracy and appropriateness. Moreover, the organization can use auditing tools to review the users who enter information into the system. This would enable the organization to identify and address any misuse or incorrect usage of the EHR system, thereby avoiding such issues in the first place and facilitating early identification of any errant users. In conclusion, bringing the ordering physician into the loop, implementing a probationary period,
and utilizing auditing tools can go a long way in ensuring that patient records are accurate and up
to date, thereby enhancing the quality of healthcare delivered.
Li, M.D., Ph.D., X. (2022). Aspirin Allergy. Medscape. Retrieved from https://emedicine.medscape.com/article/133322-overview
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BD Editors. (2019, October 5). Abdominal Cavity. Biology Dictionary. Retrieved April 16, 2022,
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WebMD. (n.d.-a) Afrin Sinus (Oxymetazoline) Nasal: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD. Retrieved April 2, 2022, from https://www.webmd.com/drugs/2/drug-12305/afrin-sinus-oxymetazoline-nasal/details