NR603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea, Exams of Nursing

Download NR603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea and more Exams Nursing in PDF only on Docsity! TEST BANK The information contained on this document has been tested and edited by professors from various universities. By purchasing this product, we guarantee you that you will get an A+. Wishing you success in your studies! With a 100 % Approved Questions and Answers Guaranteed A+ Grade NR603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea) Good Questions: 1.How can i help you today ● Im having trouble breathing. My wife made me come in. She’s worried about me. 2.Do you have any other symptoms or concerns we should discuss ● An allergic cough and runny nose. I get the cough every year during this season. 3.Do you wheeze? ● Normally just when my allergies act up. Lately ive sort of noticed wheezing at night. Thats fairly new I guess. 4. Are you short of breath when lying down? ● Im always SOB 5.Do you sleep with pillows to help you breathe? ● Just 1 pillows 6.Does anything make your cough better or worse? ● My coughing is worse when the trees shed pollen 7.Are you taking any prescription medications? ● Yes indeed. I brought my list with me here. Lisonopril 10mg daily, HCTZ 25mg daily, glipizide 5mg daily. Also use a CPAP machine, though it’s not really a medicine. 8. Are you taking any OTC or herbal medications? ● Aleve for shoulder pain and Allergra for the allergies 9.Do you have any allergies? ● Sulfa drugs, I am pretty sure im allergic to tree and grass pollen and ragweed 10. Do you now or have you ever smoked or chewed tobacco ● I was a big time smoker in the past. Started when I was 16. A pack a day, but i stopped 10 years ago. That was hard to do. 11. Do you have a problem with fatigue/tiredness ● I sure do. I get tired when i exert. I think im really out of shape, but i also dont sleep great due to sleep apnea, and this makes me tired during the day too 12. Have you been having fevers? ● no 13. Is there any swelling in your ankles? ● Sometimes. Not bad though 14. Do you have a problem with generalized weakness? ● Weakness? No, I dont think i’d call it that really 15. Do you have a cough? ● Not normally, but i have been coughing for the last couple of months ● No one has ever told me that. Is that different than a heart attack 50. Do you have high cholesterol? ● I dont think so. No one has ever told me that one 51. Do you have chills? ● no 52. Do you have a history of cystic fibrosis? ● no 53. Do you have a history of valvular heart disease? ● no 54. Have you been diagnosed with a bleeding disorder? ● No 55. Have you had chicken pox, measles mumps or rheumatic fever? ● Not that I recall 56. Are you eating alot of salty food? Not really 57. Do you have muscle pain or cramping? ● No 58. Do you have a sensation of a pounding heart in your chest? ● No 59. Do you have difficulty chewing? ● no 60. Do you have a problem with movement? ● nope 61. Did you ever have involuntary strange dance like movements? ● No i have not 62. Did you have strep throat as a child? ● Not that I remember 63. Have you recently had surgery? ● no 64. Have you eaten anything out of the ordinary lately? ● No nothing out of the ordinary 65. Do you have arthritis? ● no 66. Do you feel faint or like you might faint? ● Nope, never have passed out 67. Have you noticed any trouble with your speech? ● nope 68. Do you have a problem swallowing? ● nope Physical exam: 1. Auscultate lungs- expiratory wheeze bilaterally, possible crackles heard but only able to choose one answer 2. Inspect mouth and pharynx 3. Look up nostrils 4. Visual inspection anterior/posterior chest ( did palpate and percuss also) 5. Auscultation heart sounds- mitral valve regurgitation 6. Visual inspection of extremities 7. Palpate extremities 8. Capillary refill ? 9. BP - 144/92, normal pulse pressure, hypertensive ( the video at the end has his vitals as follows : BP- 145/90 RR20 HR 96 sa02 95%) Ed 10. Eyelid ice pack test 11. Inspect-???? 12. Fundoscopic exam KEY FINDINGS: 1. Dyspnea MSAP 2. Cough 3. BLE Edema +2 4. Bilateral Expiratory Wheezing 5. White sputum production 6. Cobblestoning oropharynx 7. Asbestos exposure 8. Smoking history 40 years one pack a day 9. Sleep apnea 10. Fatigue 11. Elevated BP 12. Use of accessory muscles 13. Hx of HTN and DM controlled Lead diagnosis: COPD Differential Diagnoses: 1. Emphysema 2. Chronic Bronchitis 3. Anemia 4. Pneumonia - community acquired 5. Heart failure 6. Asbestosis 7. Lung cancer 8. Mitral regurgitation?( I would not put that one, I can not find any resources that states it as a differential) 9. Bronchiectasis? ( I agree) 10. Pulmonary embolism? 11. Asthma ? ( i agree) 12. Tuberculosis 13. Pulmonary HTN 14. Myasthenia gravis 15. Lou Gehrig disease? I put the ones below and got 67% (I got 80% by taking out MG, Pneumo Asbestosis, lung cancer, and TB, i think they were ruled out w/ testing) Must Not Miss 1.Emphysema 2. Lung cancer u 3.Heart failure · Severe upper lobe and mid lung zone centrilobular emphysema, sparing the lung bases · No interstitial infiltrates or pleural plaques d-Dimer, blood · 44 (0-300) · Normal Echocardiogram, TTE · LVH · e/e ratio suggests mildly impaired diastolic relaxation · mild left atrial enlargement · mild aortic stenosis · mildly elevated pulmonary artery systolic pressure at rest (35mmHg) but normal RV size and function Pulmonary Function Test · FEV1 = 1.1 liters (30% predicted) · FVC – 2.5 liters (50% predicted) · FEV1/FVC = .44 (61% predicted) · Diffusing capacity of the lungs for carbon monoxide (corrected for Hgb) = 8.0 ml/min/mmHgb (40% predicted) · After albuterol FEV1 increases to 1.25 liters (an increase of 14%) and FVC increases to 3.0 liters (an increase of 20%) with FEV1/FVC decreasing to .44 (58% predicted) · Lung volumes prior to albuterol show total lung capacity TLC = 5.5 liters (92% predicted) · Residual volume = 3 liters (200% predicted) · Functional residual capacity = 3.5 liters (100% predicted) · Exertional oximetry shows SaO2 dropping to 86% on room air with walking 200 feet with patient complaining of moderate dyspnea Stress echocardiogram · Normal Troponin I · Normal Troponin T · Normal Ventilation/perfusion scan · Normal Chest PA/Lateral · Normal lung volumes · Decreased lung markings in upper lobes · Diaphragms flat · No interstitial or alveolar infiltrates · Heart size upper limits of normal · No effusions · No nodules or masses · No obvious adenopathy . Possible management plan: Final DX: COPD Admit to the hospital Meds: In-office: Duoneb (ipratropium bromide/albuterol nebulizer) 0.5mg/2.5mg per 3mL inhaled q20 min x3 if needed Rx: Albuterol HFA (90mcg/at) Sig: 1-2 puffs q4 hours prn for SOB/wheezing Disp: 1 inhaler Refill: 2 Rx: Umeclidinium-vilanterol 62.5mcg/25mcg per inhalation Sig: 1 inhalation QD Disp: 1 inhaler Refill:0 Rx: Prednisone 40mg tablet Sig: 1 tablet QD x 5 days with food Disp: 5 tablets Refill: 0 Rx: Amoxicillin-clavulanate 875mg tablet Sig4: take 1 tablet PO BID x5 days Disp: 10 tablets Refill: 0 Referrals: Pulmonology and pulmonary rehab, allergist, cardiology, nutritionist (?) Education: Encourage weight loss, diet/exercise, proper use and routine cleaning of CPAP machine to avoid PNA. Assess inhaler technique for initiation and every visit after. home oxygen needed Encourage medication compliance. Encourage a diet high in protein, high fiber, cut back on carbohydrates, monitor blood sugars and check weight same time daily, keep log for provider evaluation. Seek emergency care if patient develops severe chest pain and/or SOB that is unrelieved with rescue medications. Keep log of BPs for one week for reassessment of BP medication control (take BP morning and evening). Follow-up: Follow up in 48 hours for reevaluation. Any related CPG’s or articles found: Global Initiative for Asthma. (2021). 2021 gina main report - global initiative for asthma - gina. Global Initiative for Asthma - GINA. https://ginasthma.org/gina-reports/ Celli, B., & Wedzicha, J.(2019). Update on clinical aspects of chronic obstructive pulmonary disease. The New England journal of medicine. https://pubmed.ncbi.nlm.nih.gov/31553837/ Differential Diagnosis ( « Pulmonary hypertension is present on echo, and could be due te left heart disease or the pulmonary process that has lowered his DLCO. Mild pulmonary hypertension can also be seen ina minority of patients with OSA. Whatever its cause, his pulmonary hypertension is too mild to be playing a significant role in his dyspnea, * Aortic stenosis is also only mild by echo, Mild AS does not cause dyspnea and rarely does it contribute to it. However his AS, even though mild, can be contributing to increased afterload and HFpEF + Asthma is supported by his history of allergies, nocturnal wheezing, cough, white sputum, by wheezing on exam, and by his PFTs which show obstructive lung disease with reversibility. Asthma, however, does not explain his low DLCO, and it doesn't explain the 10 year course of his progressive dyspnea in the absence of any asthma exacerbations to this point. COPD — The Likely Diagnosis ¢ The dx of COPD nicely fits with his long smoking hx and slow progressive dyspnea. The low DLCO suggests an emphysematous process but the reaction to albuterol in the lab suggests there is also a component of reactive ainways (2.9. asthma). The severe reductions in both FEV1 (30% pred.) & DLCO (40% pred.) indicate his COPD Is severe His ABGs are reassuring that he's not retaining CO, presently, despite the severity of his underlying disease and dyspnea Emphysema would normally cause increased lung volumes on exam and chest imaging, but his obesity can mask those. His elevated RV (200% pred.) shows how significant his air trapping is from his COPD COPD & Our Patient COPD is common — the 3" leading cause of death in the U.S. and an increasing threat in the developing world His smoking for 40 pk-yrs is associated with a LR of +12 for COPD His diminished breath sounds over the upper lobes are compatible with smoking related emphysema, which is usually upper lobe predominant Any patient with a DLCO < 55% predicted has enough of a gas exchange abnormality that he or she should be evaluated for exertional hypoxemia, even if SaO, at rest is preserved. This patient, not unexpectedly, desaturated with mild exertion, and is a candidate for exertional home oxygen Case Synthesis Thus the most likely dx in our case is COPD, chiefly emphysema in type, with an underlying asthmatic component (‘asthmatic bronchitis”). One explanation for his story is that his underlying COPD has been worsening over 10 years due to normal yearly decline in lung function. His previously quiescent asthma has been flaring for 2 months, likely due to untreated environmental allergies. This likely accounts for his subacute on chronic dyspnea HFpEF is potentially playing a contributing role in his dyspnea, as is obesity  Disposition The patient was admitted to the hospital, given round the clock bronchodilators and parenteral steroids, and he improved dramatically, both symptomatically and on physical exam He was placed as an outpatient on beta agonists, inhaled steroids, and inhaled anticholinergic Rx He decided to “turn over a new leaf’ in life. He enrolled in a pulmonary rehabilitation program that also helped him lose weight When last contacted his ability to exert comfortably was at a level he had not experienced in 8 years.