NUR 680 CASE STUDY How is that possible

NUR 680 CASE STUDY How is that possible? ?

CHIEF COMPLAINT “I need to see you guys. ”

HISTORY OF PRESENT ILLNESS R. S. 48 year old male presents to the office as a new patient without any complaints. Has not seen doctor for over 30 years. No diagnoses per patient Never medically/surgically treated for anything Patient has been smoking about a pack per day for 35 years. Drinks 30 beers, one bottle of liquor, 7 shots of whiskey per week.

R. O. S. General: � No: Changes in appetite Weight loss � Denies: Weakness Fatigue Fever Chills Night Sweats Diaphoresis Skin: � Denies: Lumps Sores Itching Dryness Changes in color of: Hair Nails Rash

R. O. S. Head: � Denies: Dizziness Lightheadedness Headache Trauma LOC Ears: Eyes: � Denies: Vision Changes Blurred/double vision Spots/specks Flashing lights Excessive tearing � Does not wear corrective lenses. Last eye exam 10+ years ago. Denies: Hearing loss Tinnitus Vertigo Earaches Infection Discharge Nose/Sinuses: Denies: Itching/sneezing/bleeds Sinus pain/congestion Rhinorrhea Sinus pressure/stuffiness

R. O. S. Throat: � Denies: Bleeding gums Sore tongue Dry mouth Hoarseness Sore throat � Last Dental Exam is unknown (more than 10 years) Neck: � Denies: Swollen glands/lumps/pain/stiffnes s in neck Breasts: N/A Respiratory: Denies: Hemoptysis Dypnea Cough Wheezing Pleurisy SOB

R. O. S. Cardiovascular: � Denies: Rheumatic fever Murmurs Palpitations Orthopnea Edema Chest pressure/pain GI/GU: � Denies: Nausea/Vomiting GI upset Digestion Intolerance Dysphasia GERD Diarrhea Jaundice Bleeding Constipation Abdominal Pain Anorexia

R. O. S. Peripheral Vascular: � Denies: Pain Tingling Numbness Phlebitis Varicose veins Ankle Swelling Cyanosis Genital: � Denies: STIs Musculoskeletal: � Denies: Urinary: � Denies: Frequency/urgency Pain with micturation Flank/back pain Discharge Nocturia Hematuria Incontinence Gout/Arthritis Joint pain Stiffness Swelling Redness Tenderness Weakness Change in ROM Fractures Previous Injuries Difficulty ambulating

R. O. S. Psychiatric: � Denies: Anxiety Depression Mood swings Memory deficits Bipolar Schizophrenia Neurologic: � Denies: � Fainting Blackouts LOC Seizures Weakness Paralysis Tremors Change in memory Speech difficulties Complains of: Loss of sensation and numbness intermittently in bilateral upper extremities when sleeping. Hematologic: � Denies: Anemia Blood dyscrasias Endocrine: � Denies: Polydypsia Polyphasia Polyuria Mood swings Cold intolerance Heat intolerance E. D. Lack of energy

PAST MEDICAL HISTORY General: � Allergies: � Never treated for medical illness NKDA Medical Illness: � Denies: Asthma Cancer MI CHF COPD DM Arthritis Afib CAD HTN HLD CKD Anemia Psychiatric Illness Drug or Alcohol Dependence

PAST MEDICAL HISTORY Accidents/Injuries: � None. Surgery/Hospitalizations/Transfusions: � None Immunizations: � None reported on file, new patient. Medications: � None at this time

PAST MEDICAL HISTORY Family History/Social History: � No: DM, Anemia, Cancers, HTN, Cardiac anomalies/problems. � All family members alive and well. � Smokes 1 PPD for 35 years � See HPI for alcohol Occupation: � Mason

PAST MEDICAL HISTORY Insurance/Finance: � Health insurance provided through work Marital Status: � Single Habits: � Sleeps Safety: � Drives from 5 -8 hours per night posted speed limit, wears seat belt. Nutrition: � Eats at home most days, has dinner at restaurant with wife once a week.

PHYSICAL EXAM General: � White male pleasant and cooperative, well groomed, fit in appearance in no distress upon initial presentation to the office. Affect appears withdrawn, red hue to entire body. Vitals: � 118/68– Height/Weight/BMI: � 5’ 68– 98. 5– 16 – 0/10 – 95% on RA 8” 143 lbs, 21. 7 Skin: � Warm, pink, dry, intact with no lesions.

PHYSICAL EXAM Head: � � � Normocephalic/atraumatic, symmetric Hair buzzed. No lesions/balding/tenderness. No sinus pressure with palpation Nasal turbinates pink No nasal polyps/drainage Eyes: Acuity 20/20 uncorrected Fields intact Pupils 4 mm down to 2 mm, equal, round, reactive to light and accommodation with consensual response. � Sclera clear/white bilaterally. � No: � � � Nystagmus Ptosis Proptosis Lid lag Swelling Disc margins sharp, no hemorrhages or exudates, A: V ratio 2: 3 and no AV nicking. Red reflex intact. � Eye lids and lashes/brows intact �

PHYSICAL EXAM Ears: Tympanic membranes clear/pearly gray with appropriate landmarks � Acuity good to whisper test � Neck: � Denies: Tenderness with palpation Difficulty swallowing � � Trachea midline No pre/post auricular, tonsilar, cervical, submandibular, submental, or supra clavicular lymphadenopathy. Mouth/Pharynx: � � � Mucous membranes moist Tonsils grade 1, pink. No post-nasal drip

PHYSICAL EXAM Breasts: � N/A Respiratory: � Thorax symmetric with good expansion � Lungs hyper-resonant � Breath sounds clear and equal bilaterally with no adventitious sounds, however diminished air flow. � No Bronchophony Egophony Wheezing � Diaphragm descends 3 cm bilaterally

PHYSICAL EXAM Cardiovascular: � S 1 & S 2 with no extra heart tones � Regular Heart Rate/Rhythm Peripheral Vascular: � No BLE edema � No varicose veins � All pulses +2 and equal bilaterally, skin pink/dry/intact � Clubbing of fingers

PHYSICAL EXAM GI/GU: � Abdomen flat, equal in contour and symmetry � No lesions � Pink and uniform in color � Umbilicus midline & inverted � No scars � BS in all quadrants � No bruit � Gastric bubble percussed over stomach � No CVA tenderness � No tenderness with light/deep palpation � No masses visualized/palpated

PHYSICAL EXAM Musculoskeletal: � ROM intact in all extremities � Gait steady � Gait purposeful. Neurological: � Oriented to person, place, and time. Cranial Nerves intact without deficit, reflexes intact, no numbness/tingling.

DIAGNOSTICS Blood: � CBC diff. � CMP � Lipid Panel � Vitamin D & B 12 � TSH, T 3 PFT

DIFFERENTIAL DIAGNOSIS Asthma– ruled out with PFT.

DIAGNOSIS Chronic Obstructive Pulmonary Disease

EPIDEMIOLOGY COPD affects up to 3% of white women and 6% of white men. Third leading cause of death by 2030. 12. 7 million adults in America in 2011.

PATHOPHYSIOLOGY Chronic lung inflammation affecting the airway. Due to irritants that are inhaled � Smoking causes 40% - 70% of all cases. Airway narrowing and remodeling Increased # goblet cells Mucus-secreting glands enlarge Vascular bed changes eventually lead to pulmonary hypertension Inhaled irritants stimulate the inflammatory reaction that mediates all the changes above.

DIAGNOSTICS Imaging � � PFT (expected FEV 1 3. 2 L) FVC 3. 69 expected � � � CT X-Ray Pre = 1. 38 L 43% predicted Post = 2. 28 L 71% predicted (Moderate COPD GOLD 2) 65% increase (Statistically VERY SIGNIFICANT) FVC = 4. 72 FEV 1/FVC ratio <70%; total absence of reversibility is neither required nor the most typical result History Physical Exam findings � � � Barrel Chest Clubbing Hyper-resonant lung sounds Wheezing Prolonged expiratory cycle

SUGGESTED TREATMENT/PREVENTION Treatment Symbicort 160/4. 5 BID with spacer � Symptom based: Albuterol 2 puffs Q 4 hours prn cough/wheeze/sob Sick plan: call office if using for 24 hours with no relief

PATIENT EDUCATION Smoking cessation Immunizations � Flu Vaccine � Pneumonia Vaccine Age and other comorbid diseases Avoidance of exacerbating stimulants Hydration (He was very hydrated) Pulmonary exercises (Something this patient had a lot of) Monitoring of disease progression and treatment success Possible referral to Pulmonary

REFERENCES Grindrod, K. (2015). Management of stable chronic obstructive pulmonary disease. British Journal of Community Nursing, 20(2), 58 -64. Holmes, S. , & Scullion, J. (2015). A changing landscape: diagnosis and management of COPD. British Journal of Nursing, 24(8), 432 -440.