Exam (elaborations) NR 601 WEEK 2 COPD CASE STUDY PART 1 Primary Care of the Maturing and Aged Family (Susan Brown)

Exam (elaborations) NR 601 WEEK 2 COPD CASE STUDY PART 1 Primary Care of the Maturing and Aged Family (Susan Brown) at presents to the office today with the CC of persistent cough for the past 6 months with a recent onset of SOB. Cough is intermittent and frequent and is noted to be worse in the AM. Cough is productive. The sx are aggravated by activity and are relieved by rest. Tx has been Robitussin DM OTC without any relief of sx. Severity of sx; he is unable to walk greater than 20ft w/o stopping to catch his breath. Pt states, “I routinely walked 1 mile a day without difficulty.” Upon ROS the patient denies fever, chills, or weight loss. Denies any sx associated with HEENT. He denies chest pain and LE edema. However, he reports a persistent productive cough with white-yellowish phlegm; that is worse upon waking and SOB upon activity. PMH is positive for primary HTN. He is currently taking Metoprolol succinate ER 50 mg qd for HTN and a MV qd. PSH includes cholecystectomy and appendectomy. KDA PCN (hives). He is married with 3 children and works at a risk management firm as a Senior accountant. He is a former smoker with a 20 pack-year hx; denies ETOH or illicit drug use. FH is positive for diabetes and HTN. Father deceased at age 59 of MI and CHF. Father was a smoker; pt quit “cold turkey” at that time. Mother living and siblings all in good health. NR 601 WEEK 2 COPD CASE STUDY PART 1 Primary Care of the Maturing and Aged Family (Susan Brown) Upon PE, J.D. appears his stated age, is A&O x4, NAD, and is able to speak in full sentences. T. 98.1, P. 66, RR. 20, BP 156/94., O2 sat 94 % on RA, Ht. 68.9 “, Wt. 258, with BMI of 38.2 (obese). Cardiopulmonary exam reveals S1 S2 with no murmurs or additional heart sound, BBS clear to auscultation with faint forced expiratory wheezes in bilateral bases. R are even and unlabored. No BLE edema noted. PE otherwise normal and unremarkable. Differential Diagnosis in order of most likely: 1. Chronic Obstructive Pulmonary Disease (COPD) 2. Asthma 3. Heart Failure COPD: COPD is a progressive disease of the lungs that is characterized by airflow limitation related to chronic obstruction that impedes normal breathing; this process is preventable as well as treatable (Berg & Wright, 2016). As a result of repeated exposure to pollutants and inhaled irritants, pathological changes in the airways and alveoli occur due to an increased inflammatory response (Dunphy, Winland-Brown, Porter, & Thomas, 2019). The chronic inflammatory response leads to irreversible structural changes, a narrowing of airways passages, and parenchymal changes in the lung; the exaggerated inflammatory response in some individual is thought to a certain degree to be related to a genetic predisposition. Overproduction and hypersecretion of mucus is related to irritation of the goblet cells and permanent damage of the airway specifically the cilia lead to chronic productive cough (GOLD, 2017). In the United States, COPD is the third leading cause of death and the fourth leading cause of disability; and is associated with exorbitant medical costs. 80 to 90 % of cases of COPD are caused by cigarette smoking. Individuals that smoke and are over the age of 40 are at an increased risk for COPD. Although, smoking cessation is essential for improving lung function, permanent damage to the lung tissue may be present (Dunphy et al., 2019). The “classic “signs and symptoms of COPD include chronic cough, production of phlegm, and SOB, particularly upon exertion. The phlegm or mucus that is produced may be clear, white, yellow or greenish in color. The patient may report repetitive clearly of the throat, due to excessive mucus production in the lungs, as well as lack of energy or fatigue. The patient is most often a smoker or has a history of smoking. Additionally, there may be a history of recurrent respiratory infections. As the disease process progresses changes in the nailbeds may be observed, as clubbing; LE edema, barrel chest, cyanosis of the lips and nailbeds, increased resonance upon percussion, decreased BS, wheezes and crackles in the bases of the lungs, and distant heart sounds may be present. In severe and end-stages of COPD the patient may assume the tripod position in efforts to breathe (Rabe & Watz, 2017). Pertinent positives to support the diagnosis of COPD include: Former smoker with a 20 pack -year history, over the age of 40. Chronic cough with 6-month duration; that is productive with white-yellowish phlegm and is worse in the morning. SOB upon activity and relieved by rest. Faint forced expiratory wheezes in bilateral bases could be heard on auscultation. O2 sat on RA 94%. Typically, normal O2sat readings should be between 95-100% on RA (Hafem & Sharma, 2019). Asthma: Asthma is a chronic obstructive airway disease that is marked by airway inflammation, bronchial hyperactivity and smooth muscle spasm with intermittent reversible airflow obstruction. These physiological changes result in excessive mucus production, hypertrophy of smooth muscle, alterations in airflow, and, decreased alveolar ventilation (Liu, 2017). Asthma is caused by genetic and environmental factors. Asthma can either be extrinsic (allergic asthma) or intrinsic (non-allergic asthma) (So, Mamary & Shenoy, 2018). Changes to tissue, organ, and system functioning can occur. Airway remodeling can occur if inflammation within the airway is left untreated and inflammation becomes chronic. Airway remodeling is structural changes of the airway that involve permanent irreversible changes in the epithelial layers, hyperplasia of the mucous gland, subepithelial collagen layer thickening, as well as hypertrophy and hyperplasia of the airway smooth muscle (Russell, & Brightling, 2017). Asthma is a reversible chronic inflammatory disorder of the lungs that affects both the adult and pediatric populations. Over 26 million people in the United States have asthma; being 8.3% adults and 8.3% children. The most common chronic lung disorder in childhood is asthma (Zahran, Bailey, Damon, Garbe, & Breysse, 2018). The “classic” signs and symptoms of asthma include episodes of intermittent cough (especially at night), shortness of breath, rapid breathing, chest tightness, and wheezing upon exhalations (Liu, 2017). Patients with symptoms of asthma often present manifesting these classic signs and symptoms. However, although these symptoms are typical of asthma; they are still nonspecific. This presentation makes it challenging to distinguish asthma from other diseases or conditions of the respiratory tract. Patients with asthma will often present with extrapulmonary findings such as, nasal mucosal membranes that appear pale and swollen; from allergic rhinitis. Other physical findings that can be linked to a diagnosis of asthma are the presence of atopic dermatitis or eczema. The presence of these extrapulmonary findings along with asthmatic symptoms are known as the atopic triad (Liu, 2017). Pertinent positives to support the differential diagnosis of Asthma include: Intermittent cough and SOB upon exertion. Positive negative findings: Cough for J.D. is persistent, productive, and worse in the morning. No report of chest tightness, wheezing, or rapid breathing. Nares patent. Nasal turbinates clear without redness or edema. Nasal drainage is clear. No report of current of history of allergic rhinitis, atopic dermatitis, or eczema. Congestive Heart Failure: Heart failure (HF) is a disease process where the heart muscle cannot fill and pump efficiently; therefore, impedes the hearts ability to meet the oxygen demands of the peripheral tissues. HF is progressive and involves numerous pathophysiological changes. HF can be a result of right or left ventricular dysfunction. However, left-sided heart failure is the most common type of HF and results from an increased workload on the left ventricle (LV) from an increase in resistance due to long standing HTN (Dunphy et al., 2019). Subjective findings associated with heart failure include dyspnea, orthopnea, fatigue, lower extremity edema, tachycardia, palpations, exercise intolerance, persistent cough, fluid retention, and chest pain. Objective findings associated with heart failure include decrease tissue perfusion, resting sinus tachycardia, narrow pulse pressure, diaphoresis, and peripheral vasoconstriction. A practitioner could expect to observe manifestations of volume overload in the form of pulmonary congestion, peripheral edema, or elevated jugular venous pressure. Upon auscultation of the heart sounds an S3 gallop is suggestive of heart failure. However, the hearing of an S3 heart sound has a low sensitivity but high specificity for clinical diagnosis of heart failure (Yancy et al., 2017). Additionally, upon auscultation of the lung’s fine crackles in the lower lobes are also suggestive of congestive heart failure (Jarvis, 2016). Pertinent positives to support the differential diagnosis of HF include: History of HTN and obesity. Persistent chronic cough lasting 6 months and SOB upon walking greater than 20 ft. Additionally, he has a family hx that is significant for heart disease; as evidenced by Father died of MI & CHF at age 59 years. Pertinent negative findings: Heart S1 and S2 with no murmurs or additional heart sounds noted. Lungs clear to auscultation bilaterally with faint forced expiratory wheezes in bilateral bases. According to Jarvis (2016), fine crackles in the lower lobes are also suggestive of congestive heart failure Respirations unlabored. Legs without edema. Tests and Procedures to narrow differential: 1. Spirometry: Spirometry is the measurement of the rate at which the lung volumes change during forced breathing maneuvers. The test begins with a complete full inhalation, and then a rapid forced expiration; the expiration is maintained as long as it is possible or until an exhaled plateau volume is achieved. The results are transmitted and recorded on a graph. The three most significant indications obtained from spirometry are the forced vital capacity (FVC), the forced expiratory volume in one second (FEV1), and the ratio of FEV1/FVC. When the FVC is less than lower limits of normal and the FEV1/FVC ratio is also decreased it is indicative with the diagnosis of an obstructive airway disease. A diagnosis of asthma is determined if the FEV1/FVC ratio is less than 0.7 in adults and less than 0.85 in children (Irvin, 2018). Additionally, a FEV1/FVC ratio of less than 0.7 constitutes a diagnosis of COPD in symptomatic patients (GOLD, 2017). 2. Chest radiography: A chest x-ray is not for diagnostic purposes but can identify potential comorbidities and or rule out other etiologies. Additionally, a chest x-ray can identify the size of the heart and recognize enlargement potentially related to HF (Hollier, 2018). In early COPD the chest x-ray will appear normal (Dunphy et al., 2019). However, as COPD progresses the chest s-ray can identify abnormalities such as, hyperinflation, hyperlucency, and tapering of vasculature (GOLD, 2017). 3. 12 lead electrocardiogram: A 12 lead ECG is to assess for arrhythmias, left ventricular hypertrophy, or recent myocardial infarction, as a underlying cause of possible HF (Hollier, 2018). Additionally, an ECG is recommended for patients with reports of dyspnea, especially upon exertion, as well as for patients who are of the male gender, history of smoking, HTN, overweight or obese, and or have a family history of cardiac disease (Jin, 2019). 4. Complete blood count (CBC) with differential: A CBC with differential should be drawn to assess for anemia in the presence of dyspnea (Hollier, 2018). A CBC with diff can also identify the presence of secondary polycythemia, which occurs as a result of hypoxemia, as well as, detect any elevation in the white blood cell count which is consist with infection. The presence of eosinophils could indicate a more allergic component, which