D027 Shadow Health Treatment Plan for Dr. Douglas: Phase 3 Guide

D027 Shadow Health Treatment Plan for Dr. Douglas: Phase 3 Guide

Student Name

Western Governors University

D027 Advanced Pathopharmacological Foundations

Prof. Name:

Date

D027 Shadow Health Treatment Plan for Dr. Douglas: Phase 3 Guide

Patient Overview: Dr. Anita Douglas

Who is the patient?

Dr. Anita Douglas is a 72-year-old African American female who lives at home with her spouse. She is retired and formerly worked as a Veterinary Chief.

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Presenting Complaint and Symptoms

What are the current symptoms and history?

Dr. Douglas presents with a one-day history of fever and a three-day history of nasal congestion characterized by yellow-green mucus. She reports a productive cough with rust-colored sputum, discomfort in the right lower chest that worsens during coughing or deep breathing, fatigue, and muscle soreness.

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Lifestyle and Activity Level

What is the patient’s physical activity?

Dr. Douglas engages in light physical activity, walking for about 10 minutes, two to three days per week.

What is her diet like?

She follows a lacto-ovo vegetarian diet, which includes dairy and eggs but excludes meat.

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Vaccination and Allergies

Vaccinations	Date Administered
Influenza	3 months ago
Pneumococcal	12 years ago

Does the patient have any allergies?

No known drug allergies (NKDA) and no known food allergies (NKFA).

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Medical History and Medications

What relevant past medical conditions does she have?

• Chronic Kidney Disease stage 2 (CKD-2), ongoing for 9 years

• Pulmonary Hypertension (P-HTN)

• Hypertension (HTN) for 14 years

What medications and supplements does she take?

Medication/Supplement	Dose/Frequency	Purpose
Trandolapril/Verapamil	2 mg / 180 mg daily	Blood pressure control
Chlorothiazide	500 mg twice daily	Diuretic for hypertension
Aspirin	325 mg as needed for fever/pain	Pain relief and anti-inflammatory
Calcium	1200 mg daily	Bone health
Vitamin D	15 mcg daily	Bone health and immune support

Does she smoke or consume alcohol?

• Non-smoker

• Drinks 1-2 glasses of wine per week

• No illicit drug use

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Diagnosis

What is the diagnosis?

Dr. Douglas has been diagnosed with Community-Acquired Pneumonia (CAP), a common respiratory infection often caused by bacteria or viruses, which presents with fever, productive cough, and chest discomfort.

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Discharge Treatment Plan

What instructions and treatment have been provided?

Instruction	Details
Rest	Ensure 8 hours of rest per night
Hydration	Increase fluid intake to 64 ounces per day
Antibiotics	Start Amoxicillin/Clavulanate and Doxycycline
Medication Adjustments	Stop Aspirin
Pain and Fever Management	Use Tylenol (acetaminophen) as needed
Compliance	Complete the full antibiotic course
Missed Dose Protocol	Take missed dose as soon as remembered

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Prescription Details

Medication	Dose/Instructions
Amoxicillin/Clavulanate	500 mg/125 mg orally every 12 hours for 5 days (10 capsules)
	Take before or after food with water. Do not crush or chew.
Doxycycline	100 mg orally every 12 hours for 5 days (10 capsules)
	Take on an empty stomach (1 hour before or 2 hours after meals). Drink plenty of fluids to avoid throat irritation.

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Important Patient Instructions

What precautions should be taken with medications?

• Space doses evenly every 12 hours (morning and evening).

• Follow all patient instructions included with the medications.

• Immediately stop medication and seek emergency help if any allergic reactions occur, such as:

  • Hives or rash

  • Swelling of the body

  • Throat tightness or closing

  • Difficulty swallowing or breathing

  • Chest pain

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Follow-Up and Emergency Instructions

When should the patient seek further medical help?

A follow-up appointment is scheduled one week after discharge to monitor recovery. If symptoms worsen or new symptoms develop, the patient should seek prompt medical attention either in the office or emergency room after hours.

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References

Centers for Disease Control and Prevention. (2023). Community-Acquired Pneumonia (CAP). Retrieved from https://www.cdc.gov/pneumonia/community-acquired.html

Musher, D. M., & Thorner, A. R. (2014). Community-acquired pneumonia. New England Journal of Medicine, 371(17), 1619-1628. https://doi.org/10.1056/NEJMra1312885

Smith, R. J., & Smith, T. L. (2021). Management of bacterial pneumonia in adults. American Family Physician, 104(10), 1055-1063.