Presentation of a Case
Current Illness History: A 33-year-old white female arrives at the general medical/surgical hospital ward complaining of shortness of breath on exertion. She claims she was seen at her primary care physician’s office six months ago for similar symptoms. She was diagnosed with acute bronchitis and was treated with bronchodilators, empiric antibiotics, and a short course of oral steroid taper. This treatment did not improve her symptoms, which worsened over six months. She claims to have lost 20 pounds (9 kg) on purpose over the last year. She denies going camping, spelunking, or hunting. She denies any illness contacts. Fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding are all negative. She admits to having a cough, shortness of breath, and shortness of breath when she exerts herself.
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Her tobacco use is 33 pack-years; however, she quit smoking six months ago, shortly before the onset of symptoms. She denies using alcohol or illegal drugs. She is married and has three children aged 15 months to 5 years. She works in a cookie bakery. She has two doves as pets. She took a one-week vacation to Mexico a year ago.
There are no known drug, food, or environmental allergies.
Previous Medical Conditions: Hypertension
Previous Surgical Experience: Cholecystectomy
Every day, take 10 mg of lisinopril by mouth.
Temperature: 97.8 F; heart rate: 88; respiratory rate: 22; blood pressure: 130/86; BMI: 28
General: She is a pleasant female lying on a hospital stretcher who appears well but is anxious. She speaks freely but must stop mid-sentence due to respiratory distress.
She has diffuse rales and mild wheezing; she is tachypneic.
Cardiovascular: Her heart rate and rhythm are regular, with no murmurs, rubs, or gallops.
Bowel sounds X4 in the gastrointestinal tract. There are no bruits or pulsatile masses.
Go to: Laboratory Initial Evaluation Studies: The emergency department’s initial workup revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin of 8.3 g per; and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were taken, and the results are currently negative for bacterial growth or Gram staining.
X-rays of the chest
Mild interstitial pneumonitis is the first impression.
Visit Differential Diagnosis
Aspiration pneumonia and pneumonitis
Pneumonia caused by bacteria
Pneumocystis jiroveci pneumonia and immunodeficiency
Lung carcinoid tumors
Coccidioidomycosis and valley fever are both diseases.
Legionella pneumonia recurring
Cysts in the mediastinum
Lymphoma of the peritoneum
Mycoplasma infection that recurs
Infection with pneumococcal bacteria
Lung cancer with small cells
To further the pulmonary diagnosis, a chest CT was performed; it revealed a diffuse centrilobular micronodular pattern with no focal consolidation.
A pulmonary consultation was obtained after a chest CT revealed pulmonary consolidation. Further investigation revealed that she has two pet doves. Because she had not improved after three days of broad-spectrum antibiotics for a bacterial infection, it was decided to perform a diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections to rule out malignancy (Image 1).
Bronchoalveolar lavage produced a cloudy, muddy-looking fluid. There was no blood. Histoplasma capsulatum was discovered through cytology.
Navigate to: Diagnosis
An immunocompetent patient was diagnosed with acute pulmonary histoplasmosis based on bronchoscopic findings.
Go to: Administration
Asymptomatic pulmonary histoplasmosis resolves on its own and does not require treatment. However, a treatment decision must be made once symptoms appear, as in our previous patient. No treatment is required other than close monitoring in mild, tolerable cases. However, itraconazole treatment is recommended if symptoms become moderate or severe or persist for more than four weeks. The total duration is expected to be 6 to 12 weeks. A chest x-ray should be used to monitor the response. Furthermore, recurrence monitoring is required for several years after the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be started for at least two weeks and up to one year. Methylprednisolone cotreatment is recommended to improve pulmonary compliance and reduce inflammation, thereby improving the work of respiration.   
Histoplasmosis is a disease caused by the dimorphic fungi Histoplasma capsulatum, found in the Ohio, Missouri, and Mississippi River valleys of the United States. Histoplasma is divided into two phases: mycelial and yeast.
Histoplasmosis is caused by inhaling Histoplasma spp. Fungus microconidia into the lungs. The mycelial phase is present in the environment at room temperature, and when exposed to 37 C, such as in a host’s lungs, it transforms into budding yeast cells. This transition is a critical factor in the establishment of infection. Infection is spread primarily through the inhalation of soil particles. There has been no report of human-to-human transmission. Infected individuals may have many yeast-forming colonies that persist for years after the initial vaccination. The discovery that people who move or travel from endemic to non-endemic areas may have a reactivated infection after many months to years backs up this long-term viability. The precise mechanism of reactivation in chronic carriers, however, is unknown.
Depending on the host’s immunological status, the size of the fungal inoculum, and other factors, the infection can range from asymptomatic to life-threatening. Histoplasma spp. Grow particularly well in organic matter enriched with bird or bat excrement, giving rise to the theory that spelunking in bat-feces-rich caves increases the risk of infection. Similarly, keeping pet birds increases the rate of injection. In our case, the patient had recently traveled outside of Nebraska and owned two birds; these are her primary increased risk factors. 
Patients who are not immunocompromised present with a self-limiting respiratory infection. However, in immunocompromised hosts, disseminated histoplasmosis progresses very quickly. Histoplasmosis can be fatal within a few days if not treated aggressively and appropriately. Histoplasmosis in the lungs can progress to a systemic infection. The disseminated infection, like the pulmonary infection, is caused by exposure to infectious yeast in the soil. Compared to immunocompromised hosts, the disseminated disease progresses more slowly in immunocompetent hosts. However, the mortality rate is comparable if the infection is not treated. Macrophages ingest Histoplasma yeast after inhaling, which is the pathophysiology for disseminated disease. The macrophages enter the lymphatic system, where the disease, if not contained, spreads linearly through the lymphatic system and eventually into systemic circulation. Once this happens, a full range of diseases is possible. This fungus is contained within a phagosome within the macrophage. Thiamine is required for continued development and growth and will consume systemic thiamine. Strong cellular immunity, including macrophages, epithelial cells, and lymphocytes, surrounds yeast buds in immunocompetent hosts to keep infection localized. It will eventually become calcified as granulomatous tissue. The organisms spread to the reticuloendothelial system in immunocompromised hosts, resulting in progressive disseminated histoplasmosis.  
Infection symptoms usually appear within three to seventeen days. Immunocompetent people frequently have clinically silent manifestations with no obvious negative consequences. The acute phase of infection is characterized by nonspecific respiratory symptoms such as cough and flu. In 40% to 70% of cases, a chest x-ray is read as normal. With granulomatous changes or cavitation, chronic infection can resemble tuberculosis. Hepatosplenomegaly, adrenal enlargement, and lymphadenopathy can result from disseminated illness. Infected areas typically calcify as they heal. One of the most common causes of mediastinitis is histoplasmosis. The disease’s manifestation can vary because the infection can affect any organ in the body. 
The clinical presentation of the disease is broad-spectrum, making diagnosis difficult. Mild pulmonary illness can mimic a flu-like illness. Chronic pulmonary manifestations may occur in the presence of underlying lung disease in the severe form. The organism spreads to extrapulmonary sites in the disseminated form, resulting in proportional findings on imaging or laboratory studies. Culturing the organism is the gold standard for establishing the diagnosis of histoplasmosis. Histological analysis of samples containing the organism taken from infected organs, on the other hand, can be used to make a diagnosis. Antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assays can all be used to diagnose it. Antibodies against the fungus can also be used to make a diagnosis. 
Asymptomatic pulmonary histoplasmosis resolves on its own and does not require treatment. However, a treatment decision must be made once symptoms appear, as in our previous patient. No treatment is required other than close monitoring in mild, tolerable cases. However, itraconazole treatment is recommended if symptoms become moderate or severe or persist for more than four weeks. The expected time frame is 6 to 12 weeks. A chest x-ray should be used to monitor the patient’s response.
Furthermore, recurrence monitoring is required for several years after the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be started for at least two weeks and up to one year. Cotreatment with methylprednisolone is recommended to improve pulmonary compliance and reduce inflammation, thereby improving respiratory work.
Disseminated disease necessitates systemic antifungal therapy similar to pulmonary infection. Additionally, procedural intervention such as thoracentesis, pericardiocentesis, or abdominocentesis may be required depending on the dissemination site. Ocular involvement necessitates steroid treatment additions and ophthalmology consultation. Antifungals are not recommended for pericarditis patients because the inflammatory response from therapy would worsen the condition.
Depending on their respiratory status, patients at risk of rapid decompensation may require intensive care unit placement. Respiratory support, such as non-invasive BiPAP or invasive mechanical intubation, is required if this occurs. Surgical interventions are rarely necessary; however, bronchoscopy can be used as a diagnostic tool to collect sputum samples from the lung and a therapeutic tool to clear excess secretions from the alveoli. Patients are at risk of developing a coexisting bacterial infection, and if symptoms persist after 2 to 4 months of known infection, appropriate antibiotics should be considered. 
If not treated properly and promptly, the disease can be fatal, with complications including recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive lymph node fibrosis. Acute pulmonary histoplasmosis usually responds well to symptomatic treatment alone, with 90% of patients remaining asymptomatic. If left untreated, disseminated histoplasmosis kills within 2 to 24 months. In general, the relapse rate in acute disseminated histoplasmosis is 50%. However, the relapse rate in chronic treatment drops from 10% to 20%. Without treatment, death is imminent.
Visit: Pearls of Wisdom
While illnesses like pneumonia are more common, it is important to remember that rare diseases are always possible. Remember that not all infiltrate on a chest X-ray or chest CT are simple pneumonia. The key point is that if a patient does not improve while receiving optimal therapy for a condition, the working diagnosis is either incorrect or the treatment modality chosen by the physician should be adjusted. When this occurs, obtaining a more detailed history and referring the patient to a pulmonologist or infectious disease specialist for appropriate consultation is critical. In this case, doing so resulted in a workup that included bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing pulmonary consolidation, as demonstrated here by the presence of small, budding, intracellular yeast in tissue sized 2 to 5 microns that were easily visible on hematoxylin and eosin staining, as well as minimal, normal flora bacterial growth.
Visit: Improving Healthcare Team Outcomes
This case demonstrates the importance of involving all interprofessional healthcare team members in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, and laboratory technicians are all responsible for carrying out their duties and sharing any findings with the rest of the team. An incorrect diagnosis will almost always result in incorrect treatment, so coordinated activity, open communication, and the ability to voice concerns are all part of the dynamic that must drive such cases for patients to achieve the best possible outcomes.
For this , you will develop power point on a realistic clinical case on a topic that is of interest to you.
You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:
Subjective data: Chief Complaint; History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem; Review of Systems (ROS)
Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Labs; Vital signs; Physical examination.
Assessment: Primary Diagnosis; Differential diagnosis
Plan: Diagnostic examination; Pharmacologic treatment plan; Non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan.
Other: Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner
The presentation should consist of 11 slides. (NOT INCLUDING TITTLE AND REFERENCES SLIDES)
Incorporate a minimum of 5 current (from 2019- now) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
formatted and cited in current APA style 7 ed with support from at least 5 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 5%. WILL BE CHECKED.
NEEDS TO INCLUDE:
Chief Complaint : Includes a direct quote from patient about presenting problem
Demographics : Begins with patient initials, age, race, ethnicity and gender (5 demographics)
History of the Present Illness (HPI) : Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
Allergies – S
Includes NKA (including = Drug, Environemental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
Review of Systems (ROS) – S
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”
Vital Signs – O
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
Labs – O
Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
Medications – O
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
Screenings – O
Includes an assessment of at least 5 screening tools
Past Medical History – O
Includes, for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current AND there is a medical diagnosis for each medication listed under medications
Past Surgical History – O
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
Family History – O
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
Social History – O
Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Physical Examination – O
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
Diagnosis – A
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
Differential Diagnosis – A
Includes at least 3 differential diagnoses for the principal diagnosis
Pharmacologic treatment plan – P
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
Diagnostic/Lab Testing – P
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic examinartions clinically required at this time”
Education – P
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
Anticipatory Guidance – P
Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))
Follow up plan – P
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)
Incorporation of Current Practice Guidelines
Includes recommendations from at least 1 professional set of practice guidelines (although not the current version)
Role of the Nurse Practitioner
Includes a discussion of the role of NP pertaining to the assessment, work up, collaboration and management of the case presented AND gives at least 1 example pertaining to each of the 4 areas (assessment, work up, collaboration and management).