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NR601-CASESTUDY.docxfrom Week 2: COPD Case Study Part 1 (Initial post due Tuesday, faculty and peer responses due Sunday)
Nov 3, 2020 9:03PM
Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case.
A 62 y/o Caucasian male presents to the with complaints of persistent cough and recent onset of SOB for the past 6 months. He reports intermittent but frequent cough that becomes worse in the AM. He states the color of the phlegm when he coughs is whitish-yellow and it gets worse with activity but rest helps to relieve it. He states that he tried OTC Robitussin DM with no relief from his symptoms. Reports unable to walk greater than 20 ft w/out stopping to catch his breath as compared to last year, he would routinely walk 1 mile per day without difficulty. He denies fever, - chills, - weight loss, - otalgia, - otorrhea, - rhinorrhea, - nasal congestion, - sneezing or postnasal drip, - sore throat and swelling, - chest pain, - lower extremity edema.
Medical Hx:
History of primary HTN, currently taking 50mg of metoprolol succinate ER, and a multivitamin. Allergies to PCN which he states accompanies a rash. Past surgical history includes a cholecystectomy and appendectomy. Hx of smoking 20 packs of cigarettes a year, states he quit "cold turkey" after the passing of his father. Denies drugs or alcohol use. Patient states father is deceased at the age of 59, he had a Hx of diabetes, HTN, and smoking.
Physical Exam:
Patient alert and oriented, NAD, vitals are the following: BP elevated at 156/94, P-66, RR-20, Temp- 98.1 O2sat 94% on RA, and patient weight is 258lbs. HEENT unremarkable. CV WNL. Lungs clear to auscultation bilaterally w/ faint forced expiratory wheezes in bilateral bases, respiration unlabored, - lower exterior edema. Abdomen unremarkable.
Provide a differential diagnosis (minimum of 3) which might explain the patient's chief complaint along with a brief statement (2-3 sentences) of pathophysiology for each.
Based on the patient’s presenting symptoms the first differential diagnosis would be chronic obstructive pulmonary disorder (COPD). Chronic obstructive pulmonary disease (COPD) is characterized by poorly reversible airflow obstruction and an abnormal inflammatory response in the lungs. These inflammatory cells and mediators cause inflammation in the peribronchial region of the lungs which then in return causes fibrosis. According to Siela (2018), sputum may become more purulent as an increase in inflammatory mediators cause an increase in mucous production. The second possible diagnosis could be asthma w/acute exacerbation. Asthma is an airway obstruction in response to exposure of an irritant or allergen leading to inflammation. As inflammation occurs, epithelial hyperplasia occurs and metaplasia of goblet cells occur, causing remodeling an excess mucous production. The third possible diagnosis is congestive heart failure (CHF). The adaptive mechanisms that may be adequate to maintain the overall contractile performance of the heart at relatively normal levels become maladaptive when trying to sustain adequate cardiac performance. The primary myocardial response to chronically increased wall stress is myocyte hypertrophy, death due to apoptosis, and regeneration. This process eventually leads to remodeling, usually the eccentric type, and reduced cardiac output, causing a cascade of the neurohumoral and vascular mechanism (Malik, Brito, & Chhabra, 2020).
Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
COPD
Pertinent +: productive cough x 6 months, whitish-yellow phlegm, SOB, fatigue w/ exertion, wheezing, Hx of smoking, decreased O2 saturation
Pertinent -: -bluish-colored nailbeds and clubbing, - fever, - chills, - weight loss, - chest pain, - lower extremity edema, clear lungs bilaterally upon auscultation, respirations unlabored
Asthma w/acute exacerbation
Pertinent +: SOB w/ ambulation greater than 20ft, respiratory exhaustion, forced expiratory wheezes, frequent intermittent cough, use of hypertension medication (beta-blocker), Hx of smoking
Pertinent -: - Hx of asthma, - marked cyanosis, -dyspnea while speaking, -insufficient respiratory effort, - tachypnea, - tachycardia, -environmental allergies, -sneezing, -postnasal drip, -rhinorrhea
CHF
Pertinent +: dyspnea with exertion, increased blood pressure, cough with phlegm, Hx of HTN, Hx of smoking, family Hx of HTN and CHF leading to death
Pertinent -: - orthopnea, - paroxysmal nocturnal dyspnea, - fatigue, - weakness, - lethargy, - edema, - abdominal distention, - s3 gallop, - nocturia, - palpitations, - chest pain, - weight gain
Rank the differential in order of most likely to least likely.
1. COPD 2. Asthma w/acute exacerbation 3. CHF
Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential.
Based on the patient’s history and physical findings I would conduct a test known as spirometry. According to Siela, spirometry is the most accurate testing for COPD. With this test the patient blows into a large tube connected to a small machine to measure how much air their lungs can hold and how fast they can blow the air out. The percentage of the FVC forced out in the first second is called the FEV1. FEV stands for forced expiratory volume. The maximum speed at which you empty your lungs is called the peak expiratory flow rate (PEFR). Another test that I would perform is a chest X-ray to rule any other changes that might be related to COPD.
References:
Malik A, Brito D, Chhabra L. Congestive Heart Failure. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430873/ (Links to an external site.)
Debra Siela is an associate professor of nursing at Ball State University. (n.d.). Acute respiratory failure and COPD: Recognition and care : Nursing2020 Critical Care. https://journals.lww.com/nursingcriticalcare/Fulltext/2018/01000/Acute_respiratory_failure_and_COPD__Recognition.5.aspx
from Week 2: COPD Case Study Part 1 (Initial post due Tuesday, faculty and peer responses due Sunday)
Nov 8, 2020 6:59PM
Thank you for your response Professor. Hemoptysis is one of many presenting symptoms in patients with COPD. In adults, acute respiratory tract infections (e.g., bronchitis, pneumonia), bronchiectasis, asthma, chronic obstructive pulmonary disease, and malignancy are the most common causes of hemoptysis (Earwood & Thompson, 2015). As the healthcare provider it is important to assess for hemoptysis in patients with any respiratory infection. As it pertains to environmental factors, exposure to chemical and physical agents in the environment can cause a wide range of adverse health consequences. I would question the patient about the location in where they live and work. I also would ask how are the living conditions in the home, do they have any issues with mice or rats? How is the water system in the neighborhood of the patient’s home, also does the patient live or work in a smoke-free environment? Such questions will conduct a thorough assessment so the healthcare provider could identify potentially harmful exposures.
Reference:
Earwood, J., & Thompson, T. (2015, February 15). Hemoptysis: Evaluation and Management. https://www.aafp.org/afp/2015/0215/p243.html
What is your primary (one) diagnosis for this patient at this time?
Based on the patient’s presenting symptoms the first my primary diagnosis would be chronic obstructive pulmonary disorder (COPD). Chronic obstructive pulmonary disease (COPD) is characterized by irreversible respiratory symptoms, airflow obstruction and an abnormal inflammatory response in the lungs. Patient presents with productive chronic cough, dyspnea, and expiratory wheezing. Also, based on the patient’s spirometry results a definitive diagnosis of COPD is made with spirometry testing showing airflow obstruction when the forced expiratory volume in 1 second over vital capacity (FEV1/FVC) is less than 70% (Ansari., et 2016).
Identify the corresponding ICD-10 code.
J44.9 Chronic Obstructive Pulmonary Disease, unspecified
Provide a treatment plan for this patient's primary diagnosis which includes:
Medication*
Symbicort
Budesonide 160mcg/formoterol 4.5mcg
Sig: Two inhalations (puffs) by mouth BID
Disp: #1inhaler
No refills
Any additional testing necessary for this particular diagnosis*
No additional testing is necessary at this time
Patient education
· Encourage adherence to the prescribed treatment regimen and proper use of inhaler (Ansari., et 2016).
· Educate patient to seek immediate medical attention for new or worsening signs and symptoms (Ansari., et 2016).
· Recommend patient to lose weight and dieting (Ansari., et 2016).
· Encourage patient to increase fluids to loosen up mucus (Ansari., et 2016).
· Avoid smoking and any other irritants (Ansari., et 2016).
· Encourage patient to take all recommended vaccines such as the flu to help prevent any infections that may worsen COPD (Ansari., et 2016).
Referral
I would request a referral to pulmonary rehabilitation so that the patient could improve on his activity intolerance and perform ADLs with less dyspnea.
Follow up
The patient would need to follow up in 2 weeks. I would have the patient come back to assess new medication treatment for COPD, also monitor the patient’s blood pressure.
Provide an active problem list for this patient based on the information given in the case
COPD, hypertension, impaired physical activity, obesity, productive cough, dyspnea
Are there any changes that you would also make to this patient’s overall treatment plan at this time?
At this time, I would not make any changes to the patient’s current treatment plan.
Reference:
Ansari, K., Keaney, N., Kay, A., Price, M., Munby, J., Billett, A., ... Al Otaibi, H. (2016). Body mass index, airflow obstruction and dyspnea and body mass index, airflow obstruction, dyspnea scores, age and pack years-predictive properties of new multidimensional prognostic indices of chronic obstructive pulmonary disease in primary care. Annals of Thoracic Medicine, 11(4), 261-268. doi:10.4103/1817-1737.191866
from Week 2: COPD Case Study Part 2 (Initial post due Thursday, faculty and peer responses due Sunday)
Nov 8, 2020 7:46PM
Hi Evelyn, great post! I enjoyed reading your treatment plan. I completely agree with your primary diagnosis of COPD, I also agree with your rationale for starting the patient on antibiotics. According to The American Lung Association "My COPD Action Plan", patient’s with COPD do experience flare-ups with more coughing, more mucus and more shortness of breath. This is often caused by bacterial or viral infections. As you stated, based on the patients presenting symptoms of a productive cough with whitish-yellow mucous, this may suggest that a bacterial infection is present. Well done!
