Case study must include:
Abstract
Introduction
Risk Factors
Differential Diagnosis: Bronchiectasis, tuberculosis and asthma
Diagnostic Plan
Standard Guidelines for COPD:
Treatement Plan/Referral/follow up care:
Conclusion
PLEASE USE THE DIFFERENTIAL DIAGNOSIS I INCLUDED ABOVE, REFERENCES NO OLDER THAN 3 YEARS. USE MEDICAL TERMINOLOGY AS NURSE PRACTITIONER.
- Janis, a 59-year-old female, presents with tachypnea, dyspnea, on exertion, and mild chest discomfort. She was diagnosed with emphysema 4 years ago and was placed on a bronchodilator therapy. She has an 80 pack year history of smoking. “I feel short of breath when I walk, and my chest is sore.” She describes her chest soreness as mild pressure, rated 2 on a 1-10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing hard. She states she has had a nonproductive cough for 4 days and feels more fatigued than usual.
Subjective
Past medical history: she has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had 2 exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully.
Family history: Noncontributory
Social history: She lives with her husband who also smokes 2 packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.
Medications: Albuterol MDI, 90 mcg/inhalation, 2 puffs as needed every 4-6 hours; ipratropium bromide MDI, 18 mcg/inhalation, 2 puffs 4 times/day; ibuprofen as needed for arthritic pain.
Allergies: Janis is allergic to Keflex and penicillin
Objective: Janis is dyspneic at rest, sitting. Use of accessory muscles evident. Pursed lip breathing noted.
Vital signs: B/P 122/64; P: 92; R: 26; T: 102; SpO2: 88. AP to transverse ratio is 1:1
Skin: warm and dry
HEENT: Negative
Cardiovascular: RRR; S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2+/4+
Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on right and left anterior and lateral thorax from 2nd to 5th intercostal spaces. PFT conducted 2 months ago prior to visit showed obstructive flow patterns and reduced FEV1/FVC.
Abdomen: soft, with bowel sounds; tympanic to percussion
Neurologic: Negative
Respiratory Case study
Student name
Institution
Course name
Instructor’s name
Date
Abstract
Respiratory illnesses such as COPD can be life-threatening if they are not adequately managed through medication and lifestyle changes. Interventions should be patient-centered to increase their effectiveness and to improve patient functioning and the quality of life. The respiratory case study describes a patient with respiratory problems attributed to smoking. The main focus of treatment is to promote behavior change while encouraging adherence to medication and a healthy lifestyle.
Introduction
Respiratory illnesses are among the main causes of mortality and morbidity globally. Although pharmacological treatments are more advanced, many patients with illnesses such as COPD remain symptomatic and are at high risk of hospitalization from constant exacerbations (Wouters et al., 2020). The case study focuses on Janis, a 59-year old patient who presented with respiratory problems including dyspnea, tachypnea, and chest discomfort. The patient’s past medical history includes an emphysema diagnosis in addition to osteoarthritis and two COPD exacerbations. The patient and her husband both have a smoking habit and despite all efforts, she has made, she has not been able to get rid of the habit. The purpose of this essay is to assess the patient’s risk factors for respiratory illness and to present differential diagnoses, a diagnostic plan, COPD treatment guidelines, and her treatment plan.
Risk Factors
The patient has a history of smoking 80 packs of cigarettes a year. Her husband is also a smoker which further exposes her to second-hand smoke. According to Duan et al. (2020), tobacco smoking is one of the most significant risk factors for developing respiratory illnesses such as chronic obstructive pulmonary disorder (COPD) and lung cancer. COPD progression is also worsened by repeated exacerbations especially severe cases that require hospitalization. The patient in the case study was also diagnosed with emphysema, a condition that is part of COPD, and has also experienced two exacerbations which further increase the risk of respiratory failure. Other symptoms such as chest discomfort, dyspnea, tachypnea, and low oxygen saturation could be indicators of chronic respiratory failure.
Differential Diagnoses
Based on the patient’s symptoms, the main differential diagnoses include bronchiectasis, tuberculosis, and asthma. As per Artaraz et al. (2020), bronchiectasis is a respiratory condition that widens the lung airways, results in excess mucus build-up, and increases the risk of lung infection. Bronchiectasis patients exhibit symptoms such as dyspnea and productive persistent cough. Patients with other respiratory illnesses such as COPD, tuberculosis, severe pneumonia, and asthma are at high risk of developing bronchiectasis. The patient in the case study has COPD and experiences symptoms such as dyspnea and a persistent cough which may be symptoms of bronchiectasis.
The main symptoms of tuberculosis include persistent cough, fatigue, weight loss, chest pain including when coughing or breathing, headache, and weight loss. Tuberculosis also leads to impaired lung functioning and spirometry tests often indicate abnormalities in Forced Expiratory Volume in 1 s (FEV1) and Forced Ventilatory Capacity (FVC) especially for severe cases (Khosa et al., 2020). Janis demonstrates various symptoms of tuberculosis including fatigue, chest pain, and reduced FEV1/FVC based on a test conducted two months ago.
Asthmatic patients experience symptoms such as dyspnea, difficulty breathing, coughing, and wheezing sounds, especially during exhalation. These symptoms are mainly attributed to airflow obstruction. In addition, asthmatic patients with low control levels often demonstrate a low FEV1/FVC ratio (Jaakkola et al., 2019). Asthma is a differential diagnosis for Janis’s case because she has dyspnea, persistent dry cough, wheezing, and reduced FEV1/FVC.
Diagnostic Plan
The diagnostic plan for Janis’s case should include Chest X-Ray, Spirometry, arterial blood gases (ABGs), and ECG. As per Kakavas et al. (2021), chest X-Rays produce lung images that may reveal characteristics such as air pockets, a flattened diaphragm, or enlarged lungs which indicate that the patient has emphysema. Spirometry is a test that assesses lung functioning by measuring FVC and FEV which helps to diagnose respiratory conditions such as COPD and asthma. Examining ABGs helps to assess partial pressure of oxygen (PAO2), hydrogen ions, and partial pressure of carbon dioxide (PACO2) which in turn helps to detect oxygen levels in a patient’s blood and whether the body is expelling carbon dioxide properly. An ECG helps to assess premature ventricular contractions (PVCs), sinus tachycardia, and ischemia among patients with respiratory problems.
Standard Guidelines for COPD
COPD guidelines recommend the use of the spirometry test to detect abnormalities in FEV and FVC to assess the severity of the disease. Healthcare professionals must also assess the magnitude and nature of the symptoms including exacerbation history and the risk of future exacerbations. In addition, providers are expected to assess for comorbidities such as asthma that may increase the risk of exacerbation. The extent of FEV1 impairment helps to determine the COPD stage. Other assessment tests such as the COPD assessment test (CAT) and the modified MRC breathlessness score (mMRC) can also help to assess symptom levels and consequently, detect the risk of future exacerbations (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2020).
Initial COPD management should begin by addressing patients’ exposure to risk factors such as encouraging smoking cessation, treating comorbidities, providing healthy living advice, and offering vaccinations such as flu, pneumococcal, and COVID-19 vaccines. Patients must also be educated on self-management techniques including how to use inhalers and how to manage breathlessness. Pharmacotherapy treatment should include bronchodilators, oxygen therapy for patients with low oxygen saturation, corticosteroids to treat airway inflammation, and pulmonary rehabilitation for severe cases. Triple therapy, including a combination of inhaled corticosteroids, long-acting muscarinic antagonists, and long-acting beta2‑agonists is encouraged because of positive outcomes such as reduced exacerbations and better lung functioning in comparison to using one or two of the treatments alone. Patients should also undergo constant reassessments to determine the effectiveness of treatment measures and to make corrections where necessary (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2020).
Treatment Plan/Referral/follow up care
In addition to the medication described in the case study, Janis’s treatment plan should also include beclomethasone dipropionate, a corticosteroid. Beclomethasone should be administered at 42mcg/inhalation using a metered-dose inhaler two puffs four times a day. Her bronchodilator therapy should also be changed to a long-lasting form. In addition, glucocorticoid therapy, administered orally, may also help to relieve symptoms by reducing airway inflammation.
Apart from pharmacotherapy, the patient’s treatment should also include discussing smoking cessation. Her husband should also be included in the discussion because he is also a smoker and his habits also have a negative impact on Janis’s health. The healthcare provider should also discuss other factors that may increase the risk of COPD exacerbation such as failure to adhere to the medication regimen and consuming a high-fat diet. Janis should also be advised to get the annual flu vaccine and the pneumococcal vaccine to reduce the risk of other respiratory infections. Janis’s respiratory status should also be improved using pulmonary rehabilitation as part of follow-up care. According to Wouters et al. (2020), the main components of rehabilitation include physical exercise, medical management, breathing exercise, and nutrition counseling. Exercise helps to improve lung and heart functioning by strengthening cardiac and breathing muscles. Pulmonary rehabilitation also includes emotional management to help COPD patients deal with mood disorders such as anxiety and depression associated with lifestyle changes following the diagnosis. The main benefits of pulmonary rehabilitation include improved ability to exercise, reduced fatigue levels, improved sleep quality, and reduction in symptoms such as dyspnea and persistent cough. These benefits help to improve the quality of life for COPD patients and reduce the risk of future exacerbation and re-hospitalization.
Janis should be referred to a pulmonologist for constant evaluation to assess her respiratory status. Axson et al. (2021) explain that severe COPD can also affect the heart by causing pulmonary hypertension and leading to complications such as heart failure. Therefore, Janis should also be referred to a cardiologist to assess heart functioning. Follow-up care should include administering medication to help with smoking cessation and providing dietary recommendations. Janis should be advised to contact a healthcare professional in case any symptoms such as shortness of breath cannot be relieved using the provided medication.
Conclusion
The case study illustrated the impacts of COPD on the patient’s respiratory status including symptoms such as dyspnea and tachypnea. The patient was at high risk of respiratory failure because her oxygen saturation rates are low. She also exhibits reduced FEV1/FVC and obstructed airflow patterns. Since Janis is a smoker, treatment should focus on encouraging smoking cessation in addition to pharmacotherapy. Pulmonary rehabilitation should also be encouraged to relieve symptoms such as shortness of breath and to improve her quality of life.
References
Artaraz, A., Crichton, M., Finch, S., Abo-Leyah, H., Goeminne, P., & Aliberti, S. (2020). Development and initial validation of the bronchiectasis exacerbation and symptom tool (BEST). Respiratory Research, 21(1). https://doi.org/10.1186/s12931-019-1272-y
Axson, E., Bottle, A., Cowie, M., & Quint, J. (2021). Relationship between heart failure and the risk of acute exacerbation of COPD. Thorax, 76(8), 807-814. https://doi.org/10.1136/thoraxjnl-2020-216390
Duan, J., Cheng, W., Zeng, Y., Chen, Y., Cai, S., & Li, X. (2020). Characteristics of Patients with Chronic Obstructive Pulmonary Disease Exposed to Different Environmental Risk Factors: A Large Cross-Sectional Study</p>. International Journal of Chronic Obstructive Pulmonary Disease, 15, 2857-2867. https://doi.org/10.2147/copd.s267114
Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2020). Global Strategy for the Diagnosis, Management, and Prevention of COPD Report. https://goldcopd.org/wp-content/uploads/2020/03/GOLD-2020-POCKET-GUIDE-ver1.0_FINAL-WMV.pdf.
Jaakkola, J., Hernberg, S., Lajunen, T., Sripaijboonkij, P., Malmberg, L., & Jaakkola, M. (2019). Smoking and lung function among adults with newly onset asthma. BMJ Open Respiratory Research, 6(1), e000377. https://doi.org/10.1136/bmjresp-2018-000377
Kakavas, S., Kotsiou, O., Perlikos, F., Mermiri, M., Mavrovounis, G., Gourgoulianis, K., & Pantazopoulos, I. (2021). Pulmonary function testing in COPD: looking beyond the curtain of FEV1. Npj Primary Care Respiratory Medicine, 31(1). https://doi.org/10.1038/s41533-021-00236-w
Khosa, C., Bhatt, N., Massango, I., Azam, K., Saathoff, E., & Bakuli, A. (2020). Development of chronic lung impairment in Mozambican TB patients and associated risks. BMC Pulmonary Medicine, 20(1). https://doi.org/10.1186/s12890-020-1167-1
Wouters, E., Posthuma, R., Koopman, M., Liu, W., Sillen, M., & Hajian, B. (2020). An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease. Expert Review of Respiratory Medicine, 14(2), 149-161. https://doi.org/10.1080/17476348.2020.1700796