Case Study: Joseph Camella's Dyspnea - Week 3 iHuman, Exams of Nursing

Download Case Study: Joseph Camella's Dyspnea - Week 3 iHuman and more Exams Nursing in PDF only on Docsity! 1 NR603 - Week 3 iHuman ( Joseph Camella 66 years, Dyspnea) Good Questions: 1. How can I help you today ● I’m having trouble breathing. My wife made me come in. She’s worriedabout 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 thisseason. 3. Do you wheeze? ● Normally just when my allergies act up. Lately ive sort of noticedwheezing at night. Thats fairly new I guess. 4. Are you short of breath when lying down? ● I’m 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 2 daily, HCTZ 25mg daily, glipizide 5mg daily. Also use a CPAP machine, though it’s notreally 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 andragweed 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 theday 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? 5 ● Just when i had to have some surgery 29. Do you have a family history of heart disease? ● My father died of a heart attack when he was 52. He had HTN and DM and was a smoker. My brother had HTN and heart disease too but passedfrom cancer 30. Do you drink alcohol? ● A beer with my supper sometimes a couple more when im watching agame 31. Tell me about your work ● Construction… master carpenter, then rose to foreman. I retired at 59.Too tough to continue 32. Does your chest feel tight or heavy? ● No. 33. How severe is your difficulty breathing? ● It seems pretty bad to me. I mean, its affecting my life too much 34. Does anyone in your family have difficulty breathing? ● Not that ive noticed 35. Are you coughing up blood? ● No thank god 36. Do you have a history of lung disease? ● Never evaluated for it, though probably should be. I was exposed to asbestos years ago - and we now know thats bad 6 stuff. Of course there were the usual fumes from stuff around you on the job site, like weldingand stuff like that 37. Do you now or have you ever had cancer? ● No thank god 38. Have you had TB? ● Not that ive been told 39. Do you have asthma? ● Not been diagnosed but im starting to think maybe thats whats wrong withme now. 40. Do you have a family history of blood clots in your legs or lungs? ● no 41. Do you have a history of deep vein thrombosis or pulmonary embolism? ● I do have ugly varicose veins. Is that the same thing? 42. Do you have heart disease and/or have you ever had a heart attack? ● Never had a heart attack, but sometimes i worry about it a bit 43. Is there any swelling in your legs? ● Havent noticed that at all 44. Have you ever been diagnosed with thyroid problems? ● no 45. Do you awaken at night short of breath? 7 ● Not so far 46. Do you recently travelDo ● no 47. Is there any swelling in your feet? ● Yeah, and my shoes dont fit 48. Have you ever been told that you have a heart murmur or valve problem? ● Yes a murmur. Ive had it all my life but they said not to worry about it 49. Do you have a history of heart failure? ● 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? 10 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 11 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 12 5. Heart failure 6. Asbestosis 7. Lung cancer 8. Mitral regurgitation?( I would not put that one, I can not find any resourcesthat 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% 15 11. CTA (not recommended at this time) $1200 12. Troponin I $18-$31 13. Pulmonary ventilation/perfusion scan $487-$1702 15. Stress echocardiogram $1200 16. Cardiac stress test $540 1. CXR PA and lateral 2. CBC 3. PFT’s 4. 12 lead ECG 5. ABG 6. BNP 7. D-dimer 8. Ct chest 9. Echocardiogram, transthoracic 10. Alpha 1 antitrypsin 11. CTA (not recommended at this time) 12. Troponin T 13. Pulmonary ventilation/perfusion scan 14. PPD( statesIt is in not needed at this time ) 16 15. Stress echocardiogram 16. Cardiac stress test 17. Troponin I 18. Acetylcholine receptor antigen More? I did these tests below and got 89% - i didn’t get any that said they were not necessary — idk if maybe they don’t give that feedback anymore? 12- Lead ECG · Normal rhythm and axis · Mild LVH · No ischemic changes Alpha 1 antitrypsin, blood · Normal · 1.6 (1.5-3.5) 17 ABGs · Arterial pH 7.40 (7.35-7.45) · PaCO2 42 (35-48) · Pao2 53 (83-108) LOW · Bicarbonate 26 (22-26) · Carbon dioxide 23 (17-20) · Oxygen saturation 87% (95-99) LOW · Base Excess -2.4 (-2.4- +2.3)Brain natriuretic peptide · 3.3 · Barely above the upper limit of normalCardiac stress test · Norm 20 walking 200 feetwith patient complaining of moderate dyspnea Stress echocardiogram · Normal Troponin I · Norm alTroponin T · Normal Ventilation/perfusion scan · Norm al Chest PA/Lateral · Normal lung volumes · Decreased lung markings in upper lobes · Diaphragms flat · No interstitial or alveolar infiltrates 21 · Heart size upper limits of normal · No effusions · No nodules or masses · No obvious adenopathy . Possible management plan: Final DX: COPD Admit to the hospitalMeds: 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 22 SOB/wheezingDisp: 1 inhaler Refill: 2 Rx: Umeclidinium-vilanterol 62.5mcg/25mcg per inhalationSig: 1 inhalation QD Disp: 1 inhaler Refill:0 Rx: Prednisone 40mg tablet Sig: 1 tablet QD x 5 days with foodDisp: 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 Case Summary € Our patient is a 66 year-old former 40 pack-yr retired construction worker with 10 years of gradually increasing dyspnea. In the past 2 mos his dyspnea has significantly worsened, accompanied by cough & white sputum, but without chest pain or orthopnea. He has nocturnal wheezing, but no paroxysmal nocturnal dyspnea, His other medical conditions include obesity, type 2 DM, sleep apnea, seasonal upper respiratory allergies, & hypertension. His past exposures include welding fumes and asbestos. His family history is significant for CAD. His vital signs show: BP 145/90, RR=14, HR=96, T=98.6, SaO,=95% on ra, though he ts dyspneic at rest and is using accessory respiratory muscles. Narrowing The Still Broad Differential... Qe + Based on the H&P & CXR the patient is felt to be at risk of several cardiopulmonary diseases. The following additional data are obtained: — PFTs: FEV1/FVC=44%; FEV1=30%predicted and improves 14% after albuterol: FVC=50% predicted; TLC=92% predicted; RV=200%predicted; DLCO=40% predicted; SaO, drops from 95% to 86% on r.a. upon walking 200ft. ~ EKG: it shows LVH, but no arrhythmia and no evidence of old MI or active ischemia — Cardiac echo: it shows mild pulmonary HTN, mild aortic stenosis, and mild LVH — ABGs: PO, 66, PCO; 44, pH 7.39 — D-Dimer. negative — BNP: minimally elevated + How does one now use the all the clinical data assembled to sort through these various disorders that can present with dyspnea and a clear CXR? | 1 Differential Diagnosis é + Against the dx of bronchiectasis is his lack of chronic cough and sputum, There is nothing in his history to suggest chronic recurrent lower airway infection or any other disorder (like dysmotile cilia or immunoglobulin deficiency) that might cause bronchiectasis. HEpEF js a possible contributor to his dyspnea, with his multiple risks for it, his pedal edema, and bibasilar crackles, and LVH on EKG and TTE. His normal CXR and near normal BNP suggest HFpEF is not playing the major role, however, Restrictive neuromuscular disorders (e.g., myasthenia gravis) are not suggested by the physical exam (his strength is normal), Furthermore his PFTs do not show restriction. Restrictive disorders, however, when superposed on obstructive diseases can occasionally give normal lung volumes on PFTs. Though not technically a neuromuscular disorder, his obesity is probably contributing to increased work of breathing & hence dyspnea, and it could also contribute, as above, to his lung volumes being normal. Differential Diagnosis Pulmonary hypertension is present on echo, and could be due to left heart disease or the pulmonary process that has lowered his DLCO. Mild pulmonary hypertension can also be seen in a 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 4 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 airways (e.g. 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