DISCUSSION BOARD CASE STUDY- 1 Patients Chief Complaints: Im
DISCUSSION BOARD CASE STUDY- 1
Patients Chief Complaints:
Im falling apart. Ive been having more trouble breathing, my cough has gotten worse in the past three days, and now my ankles are beginning to swell up.
History of Present Illness:
Ahmed is a 61 year old man with COPD who presents to the emergency room with a three-day history of progressive dyspnea, cough, and increased production of clear sputum. He usually coughs up only a scant amount of clear sputum daily, and coughing is generally worse after rising in the morning. The patient denies fever, chills, night sweats, weakness, muscle aches, joint aches, and blood in the sputum. He treated himself with albuterol MDI, but respiratory distress increased despite multiple inhalations. Upon arrival at the emergency room, there were few breath sounds heard with auscultation, and the patient was so short of breath that he had difficulty climbing up onto the examiners table and completing a sentence without a long pause. He was placed on 4 L oxygen via nasal cannulae and given nebulized ipratropium and albuterol treatment
Past Medical History
History of mental illness as a young adult; one suicide attempt at age 20 HTN 10 years COPD diagnosed 6 years ago Left lateral malleolus and first metatarsal fracture repair 17 months ago Occasional episodes of acute bronchitis treated as outpatient with antibiotics Mild CVA 4 months ago, appears to have no residual neurologic deficits (-) history of TB, asbestos exposure, occupational exposure, heart disease, or asthma
Family History
Father died from lung cancer Mother is alive, age 80, also has COPD and is being treated with oxygen One sister, developed heart disease in her 50s One daughter and three grandchildren, alive and well
Social History
Patient is a recently retired beef products worker Married once and divorced at age 35, has not remarried Lives with elderly mother 2 pack/day Camel smoker for 37 years; has cut back to 5 cigarettes/day since he was diagnosed with COPD and is now willing to consider complete smoking cessation History of excessive alcohol use; has become a social drinker in last 15 years
Review of systems
Denies recent weight loss but has lost 25 pounds during past 7 years Denies progressive fatigue, loss of libido, morning headaches, and sleeping problems
Medications
HCTZ 25 mg po Q AM Amlodipine 5 mg po QD Theophylline 200 mg po BID Albuterol 180 µg MDI 2 inhalations QID PRN Ipratropium 36 µg MDI 2 inhalations QID The patient has been compliant with his medications. However, he admits that he does not like to use ipratropium because it causes dry mouth and makes him feel edgy.
Physical examination and Laboratory tests
General Appearance
Alert, thin, weak-appearing white male, who is somewhat improved and appears more comfortable after receiving oxygen and bronchodilator therapy
Vital Signs
BP 165/95 : RR 32 and labored : HT 160 cms; P 110 and regular: T 97.9°F: WT 70 kgs
Skin
Cold and dry (-) cyanosis, nodules, masses, rashes, itching, and jaundice (-) ecchymosis and petechiae Poor turgor
Head, Eyes, Ears, Nose, and Throat
PERRLA EOMs intact Eyes anicteric Normal conjunctiva Vision satisfactory with no eye pain
Fundi without AV nicking, hemorrhages, exudates, and papilledema TMs intact (-) tinnitus and ear pain Nares clear (+) pursed lip breathing Oropharynx clear with no mouth lesions Yellowed teeth
Oral mucous membranes very dry Tongue normal size No throat pain or difficulty swallowing
Neck and Lymph Nodes
Neck supple but thin (+) mild JVD (-) cervical lymphadenopathy, thyromegaly, masses, and carotid bruits
Chest and Lungs
Use of accessory muscles at rest Barrel chest appearance Poor diaphragmatic excursion bilaterally
Percussion hyper-resonant Poor breath sounds throughout Prolonged expiration with occasional mild, expiratory wheeze (-) crackles and rhonchi (-) axillary and supraclavicular lymphadenopathy
Heart
Tachycardia with normal rhythm Normal S1 and S2 Prominent S3 No rubs or murmurs
Abdomen
(+) hepatosplenomegaly, fluid wave, tenderness, and distension (-) masses, bruits, and superficial abdominal veins Normal BS
Genitalia and Rectum
Penis, testes, and scrotum normal Prostate slightly enlarged, but without nodules Heme (-) stool
No internal rectal masses palpated
Musculoskeletal and Extremities
Cyanotic nail beds (-) clubbing 1+ bilateral ankle edema to mid-calf 2+ dorsalis pedis and posterior tibial pulses bilaterally (-) spine and CVA tenderness Denies muscle aches, joint pain, and bone pain Normal range of motion throughout
Neurological
Alert and oriented Cranial nerves intact Motor 5/5 upper and lower extremities bilaterally
Strength, sensation, and deep tendon reflexes intact and symmetric Babinski down going Gait steady Denies headache and dizziness
Laboratory Blood Test Results
Arterial Blood Gases (on 4 L O2 by Cannulae)
pH 7.32
PaO2 65 mm Hg
PaCO2 54 mm Hg
SaO2 90%
Chest X-Rays
Hyperinflation with flattened diaphragm Large anteroposterior diameter Diffuse scarring and bullae in all lung fields but especially prominent in lower lobes bilaterally No effusions or infiltrates Large pulmonary vasculature
Q 1. Identify all of this patients risk factors for chronic obstructive pulmonary disease and note which of them the single most significant risk factor is. (2 marks)
No Patients risk factors for COPD Most significant risk factor
1
Q2. Identify all the clinical manifestations that are consistent with chronic bronchitis (2 Marks)
Q3. What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (2 Marks)
RELEVANT DATA from present problem Clinical significance
Q4. Identify all the abnormal assessment data and explain the pathophysiology/ clinical significance for the findings. (2 Marks)
No Abnormal assessment data Clinical significance/ Pathophysiology
Q5. What diagnostic data are RELEVANT and must be interpreted as clinically significant by the nurse? (2 Marks)
No RELEVANT DIAGNOSTIC RESULTS Clinical significance
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