NR 601 WEEK 2 COPD CASE STUDY PART 1 | PRIMARY CARE OF
THE MATURING & AGED FAMILY |CHAMBERLAIN UNIVERSITY
COLLEGE OF NURSING |INITIAL POST, FACULTY AND PEER RESPONSES
WITH 200 COMPREHENSIVE QUESTIONS, ANSWERS &
DETAILED RATIONALES
CASE STUDY PRESENTATION
CC: "I have been coughing and wheezing for the past 3 weeks."
HPI: M.M. is a 68-year-old male who presents to the clinic with complaints of a
persistent cough and wheezing that began approximately 3 weeks ago. He states
the cough is productive with clear-to-white sputum, worse in the mornings, and
occasionally interrupts his sleep. He reports shortness of breath with
activities such as walking to the mailbox, climbing stairs, or making his bed.
He admits to feeling "winded" more easily than usual. He denies fever, chills,
chest pain, hemoptysis, or recent travel. He reports a 10-pound unintentional
weight loss over the past 4 months. He states he has been using his albuterol
inhaler more frequently than prescribed, often 4–6 times per day.
PMH: Hypertension (diagnosed 12 years ago), Type 2 diabetes mellitus
(diagnosed 8 years ago), COPD (diagnosed 6 years ago), hyperlipidemia,
osteoarthritis of the knees, gastroesophageal reflux disease (GERD), and
benign prostatic hyperplasia (BPH).
MEDICATIONS: Lisinopril 20 mg daily, metformin 1000 mg BID, atorvastatin 40 mg
daily, albuterol MDI 2 puffs q4–6h PRN, tiotropium 18 mcg inhaled daily,
fluticasone/salmeterol 250/50 mcg 1 puff BID, omeprazole 20 mg daily,
acetaminophen 650 mg PRN, tamsulosin 0.4 mg daily.
ALLERGIES: Penicillin (rash).
SOCIAL HISTORY: Smoked 1.5 packs per day for 45 years (67.5 pack-year history).
Continues to smoke approximately 1 pack per day. Denies alcohol or illicit drug
use. Lives with his wife of 42 years. Retired factory worker (exposed to
industrial dust and fumes for 30 years).
FAMILY HISTORY: Father died of myocardial infarction at age 72. Mother has
1
,hypertension and type 2 diabetes. Brother has COPD.
VITALS: BP 142/86, HR 94, RR 24, Temp 98.6°F, SpO2 89% on room air, Weight
158 lbs (down 10 lbs), Height 5'10", BMI 22.7.
PHYSICAL EXAM:
- General: Alert, oriented, appears older than stated age, thin, mild respiratory
distress with pursed-lip breathing.
- HEENT: Pale conjunctiva, no JVD, no lymphadenopathy.
- Chest: Barrel-shaped chest, increased AP diameter, use of accessory muscles,
prolonged expiration, decreased breath sounds bilaterally, diffuse end-
expiratory wheezing, scattered coarse crackles at bases.
- Cardiac: Regular rate and rhythm, no murmurs, no gallops.
- Abdomen: Soft, non-tender, no organomegaly.
- Extremities: No edema, clubbing of fingers noted, capillary refill <2 seconds.
- Neuro: Alert and oriented x4, no focal deficits.
DIAGNOSTICS:
- Spirometry: FEV1 42% predicted, FVC 68% predicted, FEV1/FVC ratio 0.58.
- Post-bronchodilator FEV1: 45% predicted (improvement of 3%, not significant).
- CBC: Hgb 12.8 g/dL, Hct 39%, WBC 8.2, Plt 245,000.
- BMP: Na 138, K 4.2, Cl 102, CO2 28, BUN 16, Cr 1.0, Glucose 142.
- ABG (room air): pH 7.38, PaCO2 48, PaO2 62, HCO3 28.
- Chest X-ray: Hyperinflation, flattened diaphragms, increased AP diameter,
no acute infiltrates.
- ECG: Sinus tachycardia, no acute ischemic changes.
INITIAL POST – STUDENT RESPONSE
Question 1: What is the most likely diagnosis, and what is your differential
diagnosis list?
Answer: The most likely diagnosis is COPD exacerbation in a patient with
GOLD Stage III (severe) COPD, further classified as Group E (high risk) due to
frequent exacerbations and significant symptom burden. The patient has a
67.5 pack-year smoking history, occupational exposure, classic symptoms of
chronic bronchitis and emphysema overlap, and spirometry confirming
FEV1/FVC <0.70 with FEV1 42% predicted. The post-bronchodilator improvement
of
2
,only 3% (less than 12% and 200 mL) confirms irreversible obstruction consistent
with COPD rather than asthma.
Differential Diagnoses:
1. Acute bronchitis (viral or bacterial) – Possible given 3-week cough, but
the chronic history and spirometry findings make COPD exacerbation more
likely.
2. Community-acquired pneumonia – Chest X-ray shows no infiltrates, making
this less likely.
3. Congestive heart failure – No JVD, no edema, no crackles consistent with
pulmonary edema; BNP would help rule out.
4. Asthma-COPD overlap syndrome (ACOS) – Possible but less likely given the
minimal bronchodilator response.
5. Bronchiectasis – Possible given chronic productive cough, but no HRCT
confirmation.
6. Tuberculosis – Weight loss and chronic cough warrant PPD/IGRA and AFB
testing, though CXR lacks classic findings.
7. Lung cancer – 67.5 pack-year history and weight loss warrant CT screening,
though CXR lacks mass.
Question 2: What are the subjective and objective findings that support your
diagnosis?
Answer: Subjective findings include chronic productive cough, wheezing,
dyspnea on exertion, orthopnea (mild), unintentional weight loss, increased
albuterol use, 45-year smoking history, and occupational dust exposure.
Objective findings include tachypnea (RR 24), hypoxemia (SpO2 89%), barrel
chest, accessory muscle use, prolonged expiration, decreased breath sounds,
wheezing, coarse crackles, clubbing, FEV1/FVC <0.70, FEV1 42% predicted,
hyperinflation on CXR, and compensatory metabolic alkalosis on ABG.
Question 3: What is the GOLD classification for this patient?
Answer: The patient is GOLD Stage III (severe) based on FEV1 42% predicted
(30%–49% predicted range). He is classified as GOLD Group E (high risk)
because he has had at least 2 moderate exacerbations or 1 hospitalization
for exacerbation in the past year, and his CAT score is likely ≥10 given his
symptom burden. Group E replaces the former Groups C and D.
3
, Question 4: What diagnostic tests should be ordered?
Answer:
- Spirometry pre- and post-bronchodilator (already done).
- Chest X-ray (already done).
- ABG (already done).
- CBC (already done).
- BNP to rule out heart failure.
- Sputum culture if bacterial infection suspected.
- PPD or IGRA to rule out TB given weight loss.
- Low-dose CT chest for lung cancer screening (eligible at 50–80 years with
≥20 pack-year history).
- Alpha-1 antitrypsin level (especially if early-onset or family history).
- ECG (already done).
- Pulse oximetry (already done).
- Consider echocardiogram if cor pulmonale suspected.
- D-dimer and CT angiogram if PE suspected (not currently indicated).
Question 5: What is your treatment plan, including pharmacological and
non-pharmacological interventions?
Answer:
Pharmacological:
1. Continue tiotropium (LAMA) daily.
2. Continue fluticasone/salmeterol (ICS/LABA) BID.
3. Add roflumilast if frequent exacerbations persist despite triple therapy.
4. Short-course systemic corticosteroids: prednisone 40 mg daily x 5 days.
5. Antibiotics if bacterial infection suspected: azithromycin 500 mg x 3 days
or doxycycline 100 mg BID x 7 days.
6. Albuterol MDI 2 puffs q4–6h PRN for rescue.
7. Supplemental oxygen to maintain SpO2 88–92% (2 L/min via nasal cannula).
8. Vaccinations: influenza annually, pneumococcal (PCV20 or PCV15 + PPSV23),
COVID-19, RSV if eligible, Tdap.
9. Smoking cessation: varenicline 1 mg BID or bupropion 150 mg BID plus
nicotine replacement therapy and behavioral counseling.
Non-pharmacological:
4
THE MATURING & AGED FAMILY |CHAMBERLAIN UNIVERSITY
COLLEGE OF NURSING |INITIAL POST, FACULTY AND PEER RESPONSES
WITH 200 COMPREHENSIVE QUESTIONS, ANSWERS &
DETAILED RATIONALES
CASE STUDY PRESENTATION
CC: "I have been coughing and wheezing for the past 3 weeks."
HPI: M.M. is a 68-year-old male who presents to the clinic with complaints of a
persistent cough and wheezing that began approximately 3 weeks ago. He states
the cough is productive with clear-to-white sputum, worse in the mornings, and
occasionally interrupts his sleep. He reports shortness of breath with
activities such as walking to the mailbox, climbing stairs, or making his bed.
He admits to feeling "winded" more easily than usual. He denies fever, chills,
chest pain, hemoptysis, or recent travel. He reports a 10-pound unintentional
weight loss over the past 4 months. He states he has been using his albuterol
inhaler more frequently than prescribed, often 4–6 times per day.
PMH: Hypertension (diagnosed 12 years ago), Type 2 diabetes mellitus
(diagnosed 8 years ago), COPD (diagnosed 6 years ago), hyperlipidemia,
osteoarthritis of the knees, gastroesophageal reflux disease (GERD), and
benign prostatic hyperplasia (BPH).
MEDICATIONS: Lisinopril 20 mg daily, metformin 1000 mg BID, atorvastatin 40 mg
daily, albuterol MDI 2 puffs q4–6h PRN, tiotropium 18 mcg inhaled daily,
fluticasone/salmeterol 250/50 mcg 1 puff BID, omeprazole 20 mg daily,
acetaminophen 650 mg PRN, tamsulosin 0.4 mg daily.
ALLERGIES: Penicillin (rash).
SOCIAL HISTORY: Smoked 1.5 packs per day for 45 years (67.5 pack-year history).
Continues to smoke approximately 1 pack per day. Denies alcohol or illicit drug
use. Lives with his wife of 42 years. Retired factory worker (exposed to
industrial dust and fumes for 30 years).
FAMILY HISTORY: Father died of myocardial infarction at age 72. Mother has
1
,hypertension and type 2 diabetes. Brother has COPD.
VITALS: BP 142/86, HR 94, RR 24, Temp 98.6°F, SpO2 89% on room air, Weight
158 lbs (down 10 lbs), Height 5'10", BMI 22.7.
PHYSICAL EXAM:
- General: Alert, oriented, appears older than stated age, thin, mild respiratory
distress with pursed-lip breathing.
- HEENT: Pale conjunctiva, no JVD, no lymphadenopathy.
- Chest: Barrel-shaped chest, increased AP diameter, use of accessory muscles,
prolonged expiration, decreased breath sounds bilaterally, diffuse end-
expiratory wheezing, scattered coarse crackles at bases.
- Cardiac: Regular rate and rhythm, no murmurs, no gallops.
- Abdomen: Soft, non-tender, no organomegaly.
- Extremities: No edema, clubbing of fingers noted, capillary refill <2 seconds.
- Neuro: Alert and oriented x4, no focal deficits.
DIAGNOSTICS:
- Spirometry: FEV1 42% predicted, FVC 68% predicted, FEV1/FVC ratio 0.58.
- Post-bronchodilator FEV1: 45% predicted (improvement of 3%, not significant).
- CBC: Hgb 12.8 g/dL, Hct 39%, WBC 8.2, Plt 245,000.
- BMP: Na 138, K 4.2, Cl 102, CO2 28, BUN 16, Cr 1.0, Glucose 142.
- ABG (room air): pH 7.38, PaCO2 48, PaO2 62, HCO3 28.
- Chest X-ray: Hyperinflation, flattened diaphragms, increased AP diameter,
no acute infiltrates.
- ECG: Sinus tachycardia, no acute ischemic changes.
INITIAL POST – STUDENT RESPONSE
Question 1: What is the most likely diagnosis, and what is your differential
diagnosis list?
Answer: The most likely diagnosis is COPD exacerbation in a patient with
GOLD Stage III (severe) COPD, further classified as Group E (high risk) due to
frequent exacerbations and significant symptom burden. The patient has a
67.5 pack-year smoking history, occupational exposure, classic symptoms of
chronic bronchitis and emphysema overlap, and spirometry confirming
FEV1/FVC <0.70 with FEV1 42% predicted. The post-bronchodilator improvement
of
2
,only 3% (less than 12% and 200 mL) confirms irreversible obstruction consistent
with COPD rather than asthma.
Differential Diagnoses:
1. Acute bronchitis (viral or bacterial) – Possible given 3-week cough, but
the chronic history and spirometry findings make COPD exacerbation more
likely.
2. Community-acquired pneumonia – Chest X-ray shows no infiltrates, making
this less likely.
3. Congestive heart failure – No JVD, no edema, no crackles consistent with
pulmonary edema; BNP would help rule out.
4. Asthma-COPD overlap syndrome (ACOS) – Possible but less likely given the
minimal bronchodilator response.
5. Bronchiectasis – Possible given chronic productive cough, but no HRCT
confirmation.
6. Tuberculosis – Weight loss and chronic cough warrant PPD/IGRA and AFB
testing, though CXR lacks classic findings.
7. Lung cancer – 67.5 pack-year history and weight loss warrant CT screening,
though CXR lacks mass.
Question 2: What are the subjective and objective findings that support your
diagnosis?
Answer: Subjective findings include chronic productive cough, wheezing,
dyspnea on exertion, orthopnea (mild), unintentional weight loss, increased
albuterol use, 45-year smoking history, and occupational dust exposure.
Objective findings include tachypnea (RR 24), hypoxemia (SpO2 89%), barrel
chest, accessory muscle use, prolonged expiration, decreased breath sounds,
wheezing, coarse crackles, clubbing, FEV1/FVC <0.70, FEV1 42% predicted,
hyperinflation on CXR, and compensatory metabolic alkalosis on ABG.
Question 3: What is the GOLD classification for this patient?
Answer: The patient is GOLD Stage III (severe) based on FEV1 42% predicted
(30%–49% predicted range). He is classified as GOLD Group E (high risk)
because he has had at least 2 moderate exacerbations or 1 hospitalization
for exacerbation in the past year, and his CAT score is likely ≥10 given his
symptom burden. Group E replaces the former Groups C and D.
3
, Question 4: What diagnostic tests should be ordered?
Answer:
- Spirometry pre- and post-bronchodilator (already done).
- Chest X-ray (already done).
- ABG (already done).
- CBC (already done).
- BNP to rule out heart failure.
- Sputum culture if bacterial infection suspected.
- PPD or IGRA to rule out TB given weight loss.
- Low-dose CT chest for lung cancer screening (eligible at 50–80 years with
≥20 pack-year history).
- Alpha-1 antitrypsin level (especially if early-onset or family history).
- ECG (already done).
- Pulse oximetry (already done).
- Consider echocardiogram if cor pulmonale suspected.
- D-dimer and CT angiogram if PE suspected (not currently indicated).
Question 5: What is your treatment plan, including pharmacological and
non-pharmacological interventions?
Answer:
Pharmacological:
1. Continue tiotropium (LAMA) daily.
2. Continue fluticasone/salmeterol (ICS/LABA) BID.
3. Add roflumilast if frequent exacerbations persist despite triple therapy.
4. Short-course systemic corticosteroids: prednisone 40 mg daily x 5 days.
5. Antibiotics if bacterial infection suspected: azithromycin 500 mg x 3 days
or doxycycline 100 mg BID x 7 days.
6. Albuterol MDI 2 puffs q4–6h PRN for rescue.
7. Supplemental oxygen to maintain SpO2 88–92% (2 L/min via nasal cannula).
8. Vaccinations: influenza annually, pneumococcal (PCV20 or PCV15 + PPSV23),
COVID-19, RSV if eligible, Tdap.
9. Smoking cessation: varenicline 1 mg BID or bupropion 150 mg BID plus
nicotine replacement therapy and behavioral counseling.
Non-pharmacological:
4
