1. What is the most likely diagnosis?
The most likely diagnosis for this patient is bacterial pneumonia. My theory of bacterial pneumonia comes from the data given that the patient is coughing up green sputum and having fevers up to 102 F. Although Pneumonia can be originated from a viral infection as well, viral pneumonia will most likely present with a low-grade fever and clear to yellow sputum (Dains et al., 2019). Sweating, chills, hypotension, and tachycardia are most likely related to being bodys natural response to an infection.
Differential diagnosis: Bacterial pneumonia, Viral pneumonia, and Bronchitis.
2. What is your next diagnostic step?
Chest x-ray is indicated if the suspicion of pneumonia is present. The radiograph will allow observing changes in the thoracic area that will support the diagnosis of pneumonia. Results can help differentiate if the infection is caused by bacteria or a virus. According to Dunphy, bacterial pneumonia presents as lobar infiltrates that involve one or more lobes.
Sputum culture is necessary to identify the causative agent of the illness. Sensitivity could also be included to evaluate which antibiotic will work best for this infection.
3. What is the next step in therapy?
A broad-spectrum antibiotic treatment is a next step in therapy. Depending on the results of the sputum culture and sensitivity, a specific antibiotic could be prescribed if no improvement doesn’t occur within two to three days (Dains et al., 2019).
4. What are the potential complications of this diagnosis?
A potential complication of pneumonia is the formation of pleural effusion. According to Dunphy et al. (2019), about one-third of patients with pneumonia will have a pleural effusion that can be seen on the radiography. Another potential complication is worsening of the symptoms, which can lead to low oxygen saturation. Its important to keep in mind that this patient is diabetic. Diabetic patients are 3 times most likely to die of a respiratory infection (CDC, 2021).
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary Care4: Advanced health assessment & clinical diagnosis in primary care (6th ed.). Elsevier Health Sciences.
Diabetes And Pneumonia: Get the Facts. (2021). Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/projects/pdfs/eng_facts.pdf
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: Art and science of advanced practice nursing.
Jarvis, C. (2020). Physical examination and health assessment. Saunders.