Discussion Content
For the Respiratory topic, please read the following clinical case scenario:
____
SUBJECTIVE:
Janis, a 59 - year - old female, presents with tachypnea, dyspnea on exertion, and mild chest discomfort. She was diagnosed with emphysema four years ago and was placed on 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 as two 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 that she has had a nonproductive cough for four days and feels more fatigued than usual.
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 two 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 two 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, two puffs as needed every 4 – 6 hours; ipratropium bromide MDI, 18 mcg/inhalation, two puffs four times/day; ibuprofen as needed for arthritic pain.
Allergies: Janis is allergic to Keflex and penicillin.
OBJECTIVE:
General: Janis is dyspneic at rest, sitting. The use of accessory muscles is evident. Pursed lip breathing noted.
Vital signs: BP: 122/64; P: 92; R: 26; T: 100.2; 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 the right and left anterior and lateral thorax from the 2nd to 5th intercostal spaces. PFT conducted two months prior to the visit showed obstructive flow patterns and reduced FEV1/FVC.
Abdomen: Soft, with bowel sounds; tympanic to percussion.
Neurologic: Negative.
Based on the described case scenario, please answer two of the following questions:
-Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
-What is the most likely differential diagnosis, and why?
-What is your plan of treatment?
-What is your plan for follow-up care?
-Are any referrals needed?
-What are additional risk factors evident for this patient?
-Are there any standardized guidelines that you should use to treat this patient?
DQ Submission requirements:
The submitted paper should be according to current APA7 guidelines.
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Based on the clinical case scenario, two questions will be answered:
1. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
In this case, considering the patient's symptoms, history of smoking, and past medical history, the most appropriate diagnostic or imaging studies to consider would be:
- Chest X-ray: This can help assess for any structural abnormalities, such as emphysema, and evaluate the extent of lung damage.
- Pulmonary function tests (PFTs): Since the patient has already undergone PFTs two months prior, it would be helpful to review the results and compare them with the current symptoms. PFTs can measure lung function parameters, such as forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), which can aid in the diagnosis and monitoring of chronic obstructive pulmonary disease (COPD).
2. What is the most likely differential diagnosis, and why?
The most likely differential diagnosis for the patient in this case would be an exacerbation of COPD. The patient has a history of smoking, diagnosed emphysema, and has experienced previous COPD exacerbations. The symptoms of dyspnea on exertion, tachypnea, nonproductive cough, and reduced lung function on PFTs are consistent with an exacerbation of COPD. Additionally, the presence of wheezing and crackles on respiratory examination further supports this diagnosis.
Plan of treatment:
Based on the information provided, the treatment plan for this patient would include:
- Continue bronchodilator therapy: The patient is already on bronchodilator therapy (albuterol and ipratropium bromide MDIs), which should be continued to relieve bronchospasm and improve airflow.
- Consider systemic corticosteroids: In cases of COPD exacerbation, a short course of systemic corticosteroids, such as prednisone, is often recommended to reduce airway inflammation and improve symptoms.
- Evaluate oxygen therapy: The patient has an SpO2 of 88%, indicating hypoxemia. Supplemental oxygen therapy should be considered to maintain oxygen saturation above 90%.
- Provide smoking cessation support: Given the patient's history of smoking and unsuccessful attempts to quit, it is crucial to provide ongoing smoking cessation support and resources to promote long-term smoking cessation.
- Address arthritic pain: As needed, continue ibuprofen for arthritic pain management.
Plan for follow-up care:
- Follow-up visit in 2-4 weeks: The patient should be scheduled for a follow-up visit within 2-4 weeks to assess the response to treatment, monitor symptoms, and evaluate lung function.
- Lung function tests: Repeat PFTs should be performed to assess the response to treatment and monitor disease progression.
Referrals needed:
- Pulmonologist: A referral to a pulmonologist should be considered for further evaluation and specialized management of COPD.
- Smoking cessation program: As the patient has been unsuccessful in quitting smoking using nicotine gum replacement, a referral to a smoking cessation program would be beneficial to provide additional support and resources.
Additional risk factors evident for this patient:
- Smoking: The patient has a significant smoking history of 80 pack-years, which is a major risk factor for the development and progression of COPD.
- Exposure to secondhand smoke: The patient's husband is a heavy smoker, which may contribute to ongoing exposure to harmful smoke and exacerbation of respiratory symptoms.
Standardized guidelines to treat this patient:
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide evidence-based recommendations for the diagnosis, treatment, and management of COPD. These guidelines can be used as a reference to guide the treatment and management plan for this patient.
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