(NR 603 Week 2 Case)

The purpose of this assignment is for students to:

1. Improve their ability to formulate diagnoses based on clinical presentation of patients
2. Improve their ability to understand and apply National Guidelines for the diagnosis and treatment of Pulmonary disorders
   

   ---

Activity Learning Outcomes:

Through this discussion, the student will demonstrate the ability to:

1. Utilize healthcare delivery system resources in a fiscally responsible manner in the diagnosis and treatment of patients and families across the lifespan. (PO 5)
2. Develop management plans based on current scientific evidence and national guidelines. (PO 5)
3. Educate patients on treatment decisions (WO1)
4. Select an evidence-based article to support the plan of care for the case study patient. (WO2)
5. Analyze national guidelines and apply them to specific case study situations. (WO3)
6. Review appropriate antibiotic prescribing guidelines. (WO4)

---

Requirements – NR 603 Week 2 Pulmonary Case Discussion: Part One

Setting: A free medical clinic that provides health care for the under-insured.Your next patient, Michelle G., age 40, is a regular of the clinic and the last patient of the day. The chart states she is here for recent episodes of shortness of breath.

You enter the room and Michelle G is … in work clothes, standing up looking at a health poster on the wall. You introduce yourself and ask her what brings her to the clinic today. “I think I may have a cold. I’ve been having a hard time breathing on and off lately.”

HPI: “I notice I’m short of breath mostly at work but by the time I get home feel fine. No episodes of shortness of breath on the weekends that I can recall. But a few hours backat work and I start to feel like I cannot catch my breath again. A few months ago this happened and it was so bad I left work and went to urgent care where they gave me a breathing treatment of some kind and sent me home on an antibiotic. I would like you to give me another antibiotic. She denies sputum. No new allergy triggers noted. She denies heartburn.

PMHx: Michelle G. reports her overall health as good.

Childhood/previous illnesses: eczema as a child

Chronic illnesses: Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist ten years ago, Took allergy shots for five years with great results, now only takes Zyrtec when needed.

Surgeries: Cholecystectomy

Hospitalizations: childbirth x 3.

Immunizations: up-to-date on all vaccinations.

Allergies: Strawberries-Rash; erythromycin- severe GI upset.

Blood transfusions: none

Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20’s. Denies illicit drug use.

Sleeps 6 to 7 hours a night. Exercises four to five days per week.

Current medications: Multivitamin, Zyrtec

Social History: Married, lives with husband and 3 children. Worked in advertising up until 18 months ago when she got laid off. In order to help with the household finances she took a job as a Baker’s assistant at an Artisan Bread Bakery. She arrives at 4 a.m. every morning to begin baking breads/pastries for the day.

Family History: Children are healthy- daughter currently has a sinus infection. Parents are deceased. Mother at age 80 from congestive heart failure. Father died at age 82 from lung cancer, diagnosed when metastasized to brain. PGM: died from unknown causes, PGF: Stroke at age 82. MGM: died at 83, had HTN, atherosclerosis and many heart attacks. PGF: died at 71 from complications of COPD.

PE: Height 5’10”, Weight 140 pounds

Vital signs : BP 130/70, T 98.0, P 75, R 18 Sao2 98% on RA

General: 40-year-old Caucasian female appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless. Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.

Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.

Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender

Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses non-tender to palpation.

Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.

Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight wheezing noted inspiration and on forced expiration. Wheezing does not clear with forced cough.

CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.

Diagnostic Testing:

Review of the patient’s EMR reveals an old CXR from last winter when she had Bronchitis.

CXR Report: 11/7/2016

This is a PA and lateral chest radiograph on Ms. Michelle X, performed on 11/7/16. Clinical information: low grade fever, productive cough, malaise.

Findings: Cardio-mediastinal silhouette is normal. B/L lung fields are clear. There are no effusions. The bony thorax appears normal. No opacities or fluid. Diaphragm normal.

Impression: Normal chest radiograph without pathology.…….

You suspect an obstructive/restrictive process and order Pulmonary Function Testing

Pre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreased

Post Bronchodilator Challenge- FEV1/FVC 75%

Discussion Questions Part One:

• What is your primary … for Michelle given pattern of occurrence of symptoms, exam results, and recent history? Include the rationale and a reference for your diagnoses.
• What is your first-line treatment plan for Michelle including medications, labs, education, referrals, and follow-up? Identify the drug class of each medication you prescribe and exactly what symptom it is … to address.
• Address Michelle’s request for an antibiotic.
  

  ---

• What clinical decision did the NP make?
• What benefit would a peak flow meter offer? Should this … included?
• NR 603 Week 2 Pulmonary Case Discussion: Part One

MORE INFO 

Diagnosis and treatment of Pulmonary disorders

Introduction

Pulmonary disorders are common conditions that affect the lungs. They can be divided into three groups:

Acute chronic obstructive pulmonary disease (COPD)

Chronic bronchitis and emphysema

Pulmonary hypertension

Most pulmonary disorders are caused by structural abnormalities of the airways or lungs. Some diseases, such as asthma and cystic fibrosis, involve an allergic reaction to a substance in your body or environment. These diseases are called hypersensitivity pneumonitis (HP). Pulmonary disorders may sometimes be caused by infection with bacteria like Streptococcus pneumoniae or viruses like influenza A virus subtype H1N1 (Influenza A). In some cases, lung disease occurs due to genetic factors such as familial dysautonomia syndrome (FDS), alpha 1 antitrypsin deficiency syndrome (AATD), hereditary diffuse histiocytic leukemia-like syndrome (HDHLLS) syndrome associated with premature coronary artery disease & premature atherosclerosis syndrome].”

Most common pulmonary disorders

The most common pulmonary disorders are asthma, COPD (chronic obstructive pulmonary disease), cystic fibrosis and pneumonia.

Pneumonia is a lung infection caused by bacteria or viruses that can be fatal if not treated quickly. It’s most common in infants and young children under age five; older people are more likely to have it as a secondary complication of another condition such as emphysema, bronchitis and chronic bronchitis. Pneumonia may cause fever and chills; chest pain or pressure; cough productive of sputum; wheezing sounds when breathing out loud; shortness of breath with exercise even mild exertion at rest; loss of appetite/anorexia/weight loss especially if associated with fever due to another condition such as sepsis

Pulmonary function test

A pulmonary function test is a medical procedure that measures the strength of your lungs. It can be used to diagnose pulmonary disorders, monitor treatment and assess how well you’re recovering from injury or surgery.

The test involves breathing into a machine called a spirometer, which measures the air flow through the lungs. The results will tell doctors what’s going on with their patient’s lungs if they have any problems—and how much effort it takes to do so—whether they need additional treatment (like steroids), whether they’re getting better or worse over time based on improvement in their condition

Spirometry and flow-volume loops

Spirometry is a method used to measure lung function. It can be used to diagnose asthma and other pulmonary disorders such as bronchitis, emphysema and chronic obstructive pulmonary disease (COPD). In general, spirometry involves breathing into a machine called a spirometer that measures how much air you take in during each breath. The machine will display your vital capacity, forced expiratory volume in 1 second (FEV1) or forced vital capacity (FVC), maximal voluntary ventilation (MVV) or total lung capacity (TLC).

Flow-Volume loops are also used to measure airflow across the airways of the lungs. This test is often performed after other types of testing like sputum cytology or bronchoscopy so doctors can see if there are any changes in their patient’s condition based on these results

Bronchial provocation tests

The bronchial provocation test is a test to see if you have asthma. It involves giving you a substance that causes airway inflammation, or allergen exposure. Sometimes the provocation test can be done by giving you a drug, or exposing you to an allergen (like pollen).

In some cases this type of test may not be necessary when there’s no clear reason for concern about your symptoms and there’s no history of allergic disease in your family. But if this doesn’t work as well as it should—or if other tests reveal that you do have some form of lung disease—then these tests will help doctors figure out what kind of treatment plan is best for each patient based on their needs

Imaging modalities

• X-ray

• CT scan

• MRI (magnetic resonance imaging)

• PET scan (positron emission tomography)

Arterial blood gas analysis

Arterial blood gas analysis is a lab test that measures how well your lungs are working. It also tests for signs of inflammation and infection of the lungs, as well as lung function (the ability of your lungs to exchange oxygen for carbon dioxide).

The arterial blood gas test involves taking a sample from an artery in your arm and placing it on an analyzer that detects gases produced by muscles during physical activity or pain. The machine then spits out data about these substances—the results can range from “normal” to “abnormal” depending on what they mean for you at this point in time.

If you have abnormal results, they may indicate:

• Acidosis (high levels) – The body has too much acidity because it’s getting rid off too many salts by sweating excessively or vomiting after consuming something acidic like fruit punch; this can lead over time into chronic kidney disease if left untreated over time…

EKG or ECG screening for pulmonary disorder

• Cardiac and pulmonary disorders.

• Heart rate, rhythm and conduction.

• Pulmonary function tests (PFTs).

Medical management of respiratory disorders

• Use of inhalers, nasal steroids and beta agonists.

• Inhaled corticosteroids and leukotriene receptor antagonists.

• Long-acting bronchodilators.

• Anticholinergic agents (e.g., ipratropium bromide).

Asthma Management

Asthma is a chronic disease of the lungs. It is characterized by inflammation and constriction of the airways. The inflammation causes swelling, mucus production and narrowing of the airways in response to various triggers such as allergens, exercise or cold temperatures.

Asthma affects about 30 million adults in the United States alone; about 5% have severe asthma symptoms that require treatment with medications or medical care at least once per year. Asthma can be managed with lifestyle changes (such as avoiding smoking), proper medication use (including inhaled bronchodilators), education about how to manage your symptoms effectively and early detection so you can get help when needed

Chronic Obstructive Pulmonary Disease Management

• Smoking cessation: Quitting smoking is one of the most important steps you can take for lung health. It can help reduce your risk of developing many types of lung diseases, including chronic obstructive pulmonary disease (COPD).

• Avoidance of triggers: Some people with COPD may have symptoms that include shortness of breath, wheezing and coughing with sputum production in their lungs. These triggers should be avoided as much as possible to reduce your chances for developing COPD or another respiratory problem.

• Medications: Several medications are available to treat COPD, including beta-agonists like salmeterol and albuterol; corticosteroids such as prednisone; surfactant replacement therapy (SRT); long-acting bronchodilators such as tiotropium; anticholinergics such as ipratropium bromide/budesonide; antimuscarinic drugs such as oxitril XL [routine use]. Some patients may need combination therapy or additional medical interventions such as lung volume reduction surgery

Takeaway:

Asthma is a chronic lung disease that causes recurring periods of wheezing, chest tightness, shortness of breath and coughing.

COPD is a progressive lung disease that makes it hard to breathe.

Pneumonia is an infection in the lungs

Conclusion

The most common pulmonary disorders are asthma, chronic obstructive pulmonary disease (COPD), and pleurisy. All three of these conditions can be treated effectively with the help of a doctor.