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

NR603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea)

Typology: Exams

2022/2023

Available from 07/22/2023

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Download NR603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea) and more Exams Nursing in PDF only on Docsity! 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 16.Are you coughing up any sputum? ● Occasionally, like now. I get a cold, then bronchitis with coughing up stuff, then it goes away. Sometimes clear. Sometimes not. Its been worse the past 2 months - coughing up this gooey white stuff in the morning. Maybe like a few teaspoons worth. Disgusting. 17.When did your difficulty breathing start? ● About 10 years ago. Past 5 years its affected me more and more 18.Does anything make your difficulty breathing better or worse? ● Sitting still is the best for my breathing. Also it helps if i purse my lips when i breathe out 19.Do you become short of breath with exertion? ● Yes definitely. I can walk slowly to the postbox or from room to room ok, but im out of breath going upstairs to the bedroom or just lifting stuff 20.Are you short of breath at rest? ● Yes just these past couple months 21.Do you have any pain or other symptoms associated with your difficulty breathing? ● Symptoms? Like cough with runny nose. What else do you mean? 22.Has there been any change in your difficulty breathing over time? ● Big time! I used to be able too walk, work, and run with the best of them. But not now 23.Do you have unusual heartbeats / palpitations? ● No. 24.Do you have any pain in your chest? ● No. 25.Can you tell me about any current or past medical problems? ● High blood pressure, sleep apnea, and type 2 DM. Ive had the blood pressure thing for maybe 25 years now. The DM was maybe 5 years ago. But all these are under control. I guess thats all i can think of thats important. 26.Any recent acute or chronic infections? ● No. 27.Any previous medical, surgical, or dental procedures? ● I had my gall bladder removed 20 years ago. I had an accident 30 years back and i had a surgery to fix my shoulder and for the wound in my leg. I guess thats the big stuff 28.Have you ever been hospitalized? ● 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 passed from cancer 30.Do you drink alcohol? 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 More? 4. Tuberculosis 5. Pulmonary Embolism ALT diagnosis Asthma? Bronchiectasis ? More? Diagnostic tests: 1. CXR PA and lateral $114- $140 2. CBC: $14-$25 3. PFT’s $379-$520 4. 12 lead ECG $118-$188 5. ABG $213 6. BNP $59-$102 7. D-dimer $17-$31 8. Ct chest $350-$450 9. Echocardiogram, transthoracic $1,200-$2,500 10. Alpha 1 antitrypsin $500 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 ) Troponin I · Norm al Troponin 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 · 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/ Bollmeier, S. G., Hartmann, A. P. (2020). Management of chronic obstructive pulmonary disease: A review focusing on exacerbations. American journal of health-system pharmacy. https://doi.org/10.1093/ajhp/zxz306 AAFP. (2021, April). COPD exacerbation management. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical- recommendations/ copd-exacerbation-management.html Exercises: 88% 1 c 2 d 3 a 4 d 5 acd 6 b d 7d 8 ac 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 rr 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.
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