Exam (elaborations) NR 601 WEEK 2 COPD CASE STUDY PART 1 Primary Care of the Maturing and Aged Family (Susan Brown) (NR601)
Week 2: COPD Case Study:
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NR-601 Primary Care of the Maturing and Aged Family
Susan Brown
January 2020
J.D. is a 62 y/o Caucasian male that 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 [Show Less]