36428 - 4- pages within 24 hrs

HEENT:

· Head: Good hair distribution. No lesions at the scalp.

· Eyes/Ear: No vision or hearing impairments noted. Wears reading glasses

· Nose: No frequent nasal congestion/stuffiness or nosebleeds.

· Uvula is on midline

· Pharynx is noticeably without erythema, edema or exudate. No presence of odor is noted.

· Neck is supple, and non-tender

· Trachea is on midline.

· Thyroid palpation is non-enlarged, non-tender, and no presence of mass or nodule noted.

Lymph Nodes:

· No nodules present.

Carotids:

· No JVD. Mild AV nicking.

Lungs:

· Wheezes bilaterally at the upper lobes

· Diminished breath sounds to auscultation at lower lobes.

· Positive for short of breath

· lung wall yields no abnormal findings.

Heart:

· Heart Rate is irregular with no murmurs or gallops.

Abdomen:

· Soft, non-tender with active bowel sounds in all 4 quadrants

· No abdominal bruits.

Genitourinary:

· Deferred.

Rectal:

· Deferred

Extremities/Pulses:

· Pulses normal and present throughout. No edema.

Neurologic/Psychic:

· Alert and oriented x 3.

· CN II-XII tested intact.

· Strength and sensation symmetric and intact.

· Appropriate and aware of surroundings

Diagnostic Test:

· EKG: Normal Regular Sinus Rhythm

· Chest X ray: Hyperinflation of both lungs and an increased anterior-posterior chest wall diameter.

Assessment

1- COPD - J44.9:

2- Asthma - J45.909:

3- Stable angina pectoris - I20.9:

Diagnosis Differential:

1-Acute coronary syndrome - I24.9: Even though there is presence of exacerbation of short of breath, there is no chest pain radiating to both arms which is persistent in ACS. Additionally, ACS has chest pain associated with diaphoresis. We can fairly rule it out.

2-Pleural Effusion - J91.8: X Ray does not show any blunting of the right and left costophrenic angles which is highly considered a suspicious of pleural effusion (Blanchette, Grenier, 2014). Chest X ray shows hyperinflation of both lungs and an increased anterior-posterior chest wall diameter. Despite of some similarities, per chest X ray, patient may not have pleural effusion.

3-Pulmonary embolism - I26. 9: Symptoms as increased or irregular heartbeat, difficulty catching breath, which may develop either suddenly. Chest pain that is sharp and stabbing. It is a medical emergency. We can rule it out as well.

Agreeing with the patient’s problems as listed in the assessment and ruling out those of the diagnostic differentials, will now conduct a plan of care as below.

Plan of Care

COPD - J44.9: Difficulty in emptying air out of the lungs (airflow obstruction) can lead to shortness of breath or feeling tired because you are working harder to breathe. COPD is a term that is used to include chronic bronchitis, emphysema, or a combination of both conditions (American thoracic society, 2018). Symptoms are persistent to COPD and patient has history of emphysema and he is a smoker. This our primary diagnosis. A recent chest x-ray also showed evidence of emphysema with hyperinflation of both lungs and an increased anterior-posterior chest wall diameter. The plan of care is very much about the COPD which, we believe is this patient main problem.

· The patient reported that she was previously given samples of an inhaler for management of her emphysema symptoms. The National Institutes of Health (NIH) (2013) recommend an inhaled bronchodilator for management of emphysema symptoms. Bronchodilators relax the muscles around your airways, which makes breathing easier. Combivent is used as an inhaled medication to prevent bronchospasm in people with chronic obstructive pulmonary disease (COPD) who are also using other medicines to control their condition (drugs.com, 2014).

Asthma - J45.909: It’s a disease where it is difficult to empty the air out of the lungs, and It is not uncommon, however for a patient with COPD to also have some degree of asthma. flare-ups or asthma attacks are often caused by allergies and exposure to allergens such as pet dander, dust mites, pollen or mold. Non-allergic triggers include smoke, pollution or cold air or changes in weather.

· Plan of care will have the same as above which is our primary diagnostic. We will not focus on the asthma as a problem for the patient but will cover some related asthma issues that are present in COPD.

Stable angina pectoris - I20.9: As patient’s symptoms include midsternal chest pain described as a tightness and pressure that radiated down left arm. As Talbert stated, “there are three factors that determine myocardial oxygen demand: heart rate, contractility, and intra-myocardial wall tension, with the latter considered the most important” (Talbert, 2011).

· Will not consider it in the care plan as it is not relevant for this patient case.

Considering the plan, we will have as follow:

Medication:

· Oxygen: Administration of oxygen can help the patient breathe better even though COPD patient runs low on oxygen saturation: 2 LNC.

· Combivent: 2 puff Q4 hours as needed.

· Advair (fluticasone and salmeterol): 1 puff q4 hours PRN is recommended to prevent flare ups or worsening of COPD associated with chronic bronchitis or emphysema (drugs.com, 2015).

· Azithromycin 250 mg Po BID, patient has low grade fever. Do not want to miss a possible underneath pneumonia.

· Percocet 5/325 mg PO Q4H for pain

Will order blood work and tests

· CBC, CMP, Lipid Panel, Liver Function Panel, BNP.

Education:

· Educate patient on the possibility of worsening depression even on medication.

· Educate patient that treatment can take up to 8 weeks to take full effect, so she should not be discouraged if she does not suddenly feel better.

· Suppression of allergens, environmental or seasonal

· Educate patient on particular pursed lip breathing techniques.

· Exercise regularly

· Reduce total daily intake of calories to lose weight or maintain healthy weight eventually.

· Reduce alcohol intact as appropriate.

· Smoking cessation, support and help will be provided: Nicotine patch or Chantix.

· Will advise patient to be up to date for his immunization: Flu and Pneumonia vaccines.

· At this present time, there is no cardiac issue that warrants a cardiology work up.

· Will see patient in 2-10 weeks, if no improvement will refer patient to a lung doctor.

· Referral: The patient may need to follow up with a Pulmonologist for the management of her COPD.

Clinical Reflection

Without a doubt, Chronic obstructive pulmonary disease (COPD) is a global problem and a major cause of chronic morbidity and mortality (Global initiative for chronic obstructive lung disease, GOLD 2016). Thus, as nurse practitioner we are going to play a central role in taking care of those patients living in the conditions of COPD. Reports show a need to structure the care of patients with COPD in primary health care. So, as it is in this patient, it is imperative to emphasize an important point which is each individual is different and complex. The challenge of individualizing care expressed the importance of cooperation with other professions in the care of patients with COPD. And that, once the patient feels she is in a place to seek outside help, she should definitely consider local resources in her neighborhood for support.

Should no improvement be noticed and despite all efforts, a referral to the pneumologist is highly recommended.

References

American Thoracic Society. (2018). Chronic Obstructive Pulmonary Disease (COPD). Retrieved

from http://www.thoracic.org/patients/patient-resources/resources/copd-intro.pdf

Drugs.com. (2016). Tessalon - FDA prescribing information, side effects and uses. Retrieved

Drugs.com. (2015). Levofloxacin: Indications, Side Effects, Warnings - Drugs.com. Retrieved

from https://www.drugs.com/cdi/levofloxacin.html

National Institutes of Health. (2013). How Is COPD Treated? Retrieved from

http://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment

Talbert, L. (2011). Chapter 23. Ischemic heart disease. In: Talbert RL, DiPiro JT, Matzke GR, et

al (Eds), Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY:

McGraw-Hill; 2011.