Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 72-year-old man presents to primary care for a sick visit, with the chief complaint of a 1-day history of fever, productive cough with yellow sputum, and increasing shortness of breath. His vital signs are as follows: his temp is 99.8°F or 37.6°C, BP 140/85, heart rate 98 beats per minute, and respiratory rate 22 at rest.
O2 saturation is 94% on room air, he has a history of hypertension and type 2 diabetes, at guideline-based goals. He is a former smoker, quitting about 35 years ago with approximately a 25-pack year history. On physical exam he has crackles in his lower right lung fields, no wheezing, and is able to speak in complete sentences. He answers questions appropriately, has moist mucous membranes and reports voiding about 1 hour ago.
He denies GI distress but states his appetite is not what it usually is. He lives in a single-story home with his spouse and adult child, both of whom are with him for today's visit. His laboratory results include mild leukocytosis and renal function is within normal limits. There is no evidence of anemia and chest X-ray confirms a right lower lobe infiltrate consistent with pneumonia.
Which of the following is the most appropriate treatment location for this patient?
A: Intensive care unit.
B: At home with careful follow-up.
C: Inpatient medical ward.
D: Long-term care facility.
Correct answer is B: At home with careful follow-up. Where should we start with this question? First, determine what kind of a question it is. And given that this is an older adult with community-acquired pneumonia, this is a plan question as we're being asked to determine where he should be treated.
Keep in mind, with the exception of the worst years of the COVID-19 pandemic, pneumonia has remained the number one cause of infectious disease deaths. Period. Full stop. Indeed, when I was part of the community of healthcare providers who took care of people with HIV in the late 80s and early 90s, where there was virtually no treatment options, and it was virtually and universally fatal condition, pneumonia still remained the overall number one cause of infectious disease death.
Community-acquired pneumonia is defined as an infection of the bronchi in the lungs, occurring while residing in the community, and usually in a patient who can be treated in the outpatient setting. What is often not appreciated by healthcare providers, whose experience is largely reflective of inpatient hospital care, the community is the most common location for pneumonia care, and hence why, in part, it's called community-acquired pneumonia, AKA CAP.
One of the most important parts of treating a person with CAP is to determine whether the patient is able to be safely and effectively be treated as an outpatient for this potentially fatal disease. A number of factors figure into this, including the patient's GI function, presence of a helpful caregiver at home, health literacy, ability for clinical follow-up, and relatively stable vital signs, as well as knowing concerning clinical findings including lab and X-ray.
In addition, a number of clinical predictive tools have been developed to help determine where the patient would be best treated, and these are all backed up with research on outcomes as well as mortality and morbidity for community-acquired pneumonia. Some of the more commonly used tools include the CURB-65 and the PSI, or the Pneumonia Severity Index. For those of you who practice in the inpatient setting, you are probably familiar with the PSI, and it includes more data that can be added to it than CURB-65.
On the outpatient setting, we often lean more on CURB-65. Now, lest you think, ‘Ray, I need to memorize what's on CURB-65 and PSI.’ No, no, no, don't worry about that. There's no expectation on the NP boards that you'll memorize any or all of the pneumonia clinical predictive tools. Hey, that's why we have app. So, we can just pull these up and look at them, plug in the data.
And lo and behold we have our answer. So, that's a good example of ‘look up information’ on the boards not ‘walking around’ information, but you're walking around information on the boards-in other words, information that everyone should know regardless of preparation to be a safe and effective primary care provider, you should know that there are standardized scales for seeing where a person would be best treated for community-acquired pneumonia.
So, when you look at something like the CURB-65, I'm going to go over its components, it's very helpful when assessing a person with CAP. And always, always, always include the results in your clinical note. So, the next person that sees that patient will say, ‘Oh yeah, this person was properly assessed. It's safe to be treated at home.’
Or, ‘Oh, that's why the patient got admitted to the ICU or the medical floor or whatever.’ So, the components of CURB-65 are as follows: in each item that’s measured in the affirmative gets one point. Maximum score is five points. As I go through this I'm going to walk you through the patient score. So, the C in CURB-65 is representative of confusion of new onset.
We're told he's alert and oriented. He gets zero points. The U stands for blood urea nitrogen greater than 19. And we're told that his renal labs are acceptable. He gets zero points. And by the way, that's more a surrogate marker not only for renal function but hydration. Because people with intact renal function can have a really high BUNs when they're dry.
And we have a lot of evidence with this guy that he sketches in hydration. He has moist mucous membranes. Nice, big, fat pulse pressure on his blood pressure. And he recently urinated. The R in CURB-65 stands for respiratory rate of 30 breaths per minute or greater. His respiratory rate is in the low 20s, zero points. B for blood pressure, blood pressure less than 90mm of mercury systolic or diastolic BP of less than 60mm of mercury.
He has that normal blood pressure with that great, big, fat pulse pressure reflective of reasonable hydration and cardiac output. He gets no points for deranged vital signs. The 65 on CURB-65 means for age 65 years or older. He does get a single point for his age.
That's a non-modifiable point. We can't make him younger than 65. Therefore, his CUFB-65 score is one. How should this be interpreted? For patients with a CURB-65 score of 0 to 1 you treat as an outpatient. These patients have very low risk for poor CAP outcome. Now, close follow-up or in-person visit in a couple of days or telehealth in the first few days is advised.
Of course, you'd also discuss with patients and family worsening shortness of breath, you start throwing up, you can't keep fluids down, go pronto to the ER. That would be what you would tell the person. But for the most part, these folks do very well in the outpatient setting. Now, I'm not saying that they feel great in a couple of days, but they really do start to turn a corner after maybe 3 to 5 days of therapy.
Now, a CURB score to consider a short stay in the hospital or watch very closely as an outpatient. And one of the most common ways this presents will be with an older adult over the age of 65, one point for that. With new-onset confusion delirium. I see this a lot. People like in their 80s who develop pneumonia.
You're living at home, they have attentive caregivers. They get a point for their age, now new-onset confusion. But GI function is intact, appropriate and attentive caregivers around. Lot of those folks can be managed as outpatients with very close follow-up, and most will do quite well. CURB score of two: consider a short stay in the hospital or watch very closely as an outpatient.
How does this present? Quite often this will be a person of rather advanced age, like, let's say, a person who's in their 80s comes down with the community-acquired pneumonia. So that one point for being over the age of 65 and now has new-onset confusion. And we all know infectious disease is one of the most common triggers for delirium in older adults.
But let's say that this is an 85-year-old, new-onset confusion, non-deranged vital signs. So, respiratory rates under 30, BP is acceptable. Intact GI function, strong social support at home. So, if things don't go well, the person will be scooped up and taken to the local hospital. Then that person with a CURB score of two can be very safely managed at home with really close follow-up.
But nonetheless safely managed at home. Now, when CURB score’s 3 to 5, you've got deranged vital signs and these folks require hospitalization with consideration as to whether they need to be in the ICU. There’ll be those deranged vital signs as I said, usually worrisome labs. You're going to need inpatient care.
With this as a backdrop, now let's take a look at the question and the options. A 72-year-old man presents to primary care for a sick visit with a chief complaint of a 1-day history of fever, productive cough with yellow sputum, and increasing shortness of breath. His vital signs are as follows: his temp is 99.8°F or 37.6°C, BP 140/85, heart rate 98 beats per minute, and a respiratory rate of 22 at rest. O2 sat is 94% on room air. Has a history of hypertension and type 2 diabetes, at guideline-based goals. He's a former smoker, quitting about 35 years ago with a 25-pack year cigarette smoking history. On physical exam, he has crackles in his right lower lung, no wheezing, and is able to speak in complete sentences.
He answers questions appropriately, has moist mucous membranes, and reports voiding about 1 hour ago, and denies GI distress, but states his appetite is not what it usually is. He lives in a single-story home with his spouse and adult child, both of whom are with him for today's lesson. His laboratory results include a mild leukocytosis and renal function is within normal limits.
There's no evidence of anemia, and chest X-ray confirms a right lower lobe infiltrate consistent with pneumonia. Which of the following is the most appropriate treatment location for this patient? A: Intensive care unit. This is incorrect, of course. The ICU should be reserved for patients with CAP who have evidence of hemodynamic instability and significant respiratory distress. B: At home with careful follow-up.
This is, of course, the correct answer. Keep in mind, one more time, non-deranged vital signs, intact GI function and cognition, and a report of living with two adults, a spouse and an adult child-yeah, obviously you would want to question the spouse and the child about their availability for caring for this person, particularly during the first 3 to 5 days of pneumonia therapy.
But these all point towards successful outpatient therapy. Obviously, an antimicrobial needs to be prescribed. And I'm going to cover this in a future Q&A. C: Inpatient medical ward. This option should be considered with a CURB-65 score of two, maybe three. And even you might consider inpatient therapy if this guy had zero support at home, because it wouldn't be all that safe to send him home with no one to look after him.
Or maybe an observation unit. Something along those lines. But we know he's got the support at home. D: Long-term care facility. Clearly that's incorrect. Key takeaway: in the outpatient setting, particularly for individuals connected to primary care practice, patients with serious illness, such as community-acquired pneumonia, often present earlier in the disease process. As a result, outpatient treatment can be successful and hospitalization avoided.
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