Case Presentation Mrs. Bovier

Case Presentation

Mrs. Bovier is a 72-year-old woman who recently spent 5 days in hospital for pneumonia, where she received intravenous antibiotics and respiratory therapy. She was discharged 1 week ago and has been at home with her elderly husband, who assists in her care. She has arthritis and typically is not very physically active.

 Mrs. Bovier returned to her primary care provider for a checkup and complained of increasing difficulty breathing, headache, and coughing up yellowish-colored sputum. On examination, she was found to have a lowgrade fever; chest auscultation revealed areas of atelectasis; oxygen saturation (PaO2 ) was 91%; and she was diaphoretic. A sputum specimen was obtained for culture and sensitivity that later revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA). Chest x-ray confirmed pulmonary congestion and atelectasis. Laboratory analysis showed an elevated white blood cell count, the presence of band cells (immature neutrophils), and an elevated erythrocyte sedimentation rate. Mrs. Bovier was again hospitalized because of the severity of her respiratory distress; the need for intravenous antibiotics to manage the MRSA pulmonary infection; pulmonary therapy to assist in resolving her pulmonary congestion; and the need for contact isolation because of her recurrent pneumonia and MRSA infection. Mrs. Bovier’s age and lack of physical activity are complications that may influence MRSA treatment, requiring a more watchful course of initial therapy. Hospital care for Mrs. Bovier included instruction in methods to improve the productivity of her cough, humidified oxygen to assist with loosening secretions while improving ventilation, and respiratory therapy to help with expectoration and to facilitate lung expansion and air exchange. She received intravenous vancomycin, mucolytic agents, a bronchodilator, and expectorants to treat her pulmonary disease and assist in breathing.

On discharge, Mrs. Bovier received instructions in the proper technique for effective hand hygiene; the importance of avoiding large crowds of people as well as areas where people are smoking, to diminish her exposure to irritating respiratory stimuli; and the need to increase her physical activity, including frequent ambulation in her home, to help stimulate deep breathing and avoid peripheral vascular clot formation. She demonstrated understanding of her medication regimens and the need to maintain adequate food and fluid intake to support her immune system and to provide energy while healing. The need for rest to promote healing was also emphasized. Finally, Mrs. Bovier was instructed on the warning signs of recurring pulmonary disease or dysfunction.

 Case Analysis Questions

1. What risk factors does Mrs. Bovier have that put her at risk for the development of MRSA?

2. What clinical findings did Mrs. Bovier have consistent with the concept of infection?