NR 601 COPD Case Study Part 2 Week 2
Case Study – Part 2
You ordered a CXR and spirometry at the previous visit and he returns today to review the results. Physical exam and symptoms are unchanged since my last visit. Vital signs at this visit are: Temp-98.3, P-68, RR-20, BP 152/90, Height 68.9in., Weight 258 pounds, O2sat 94% on RA
CXR Result:
No acute infiltrates or consolidations are seen. Cardiac and mediastinal silhouettes are normal. No hilar enlargement is evident. Osseous thorax is intact.
Requirements/Questions:
What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
Identify the corresponding ICD-10 code.
Provide a treatment plan for this patient’s primary diagnosis which includes
● Medication*
● Any additional testing necessary for this particular diagnosis*
● Referral
● Follow up
Provide an active problem list for this patient based on the information given in the case.
Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBP argument for each treatment or testing decision.
*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based practice (EBP) argument.
Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.
Over-the-counter (OTC) and RXs must be written in full as if handing a prescription to the patient in the office.
Example:
Amoxicillin 500 mg capsule 1 tab po BID q 10 days Disp #20 no refills DISCUSSION CONTENT
Category Points
%
Description
Week 2: COPD Case Study Part 2 Example Approach
List Of Problem
COPD
Short of breath Cough
Wheeze Hypertension Overweight BMI 27.7 Assessment
Chronic Obstructive Pulmonary Disease
COPD is chronic irreversible inflammation that leads to obstruction, and by limiting the airflow the gasses get trapped in the lung (Berg and Wright, 2016). Chronic bronchiolitis or emphysema is the most common cause of COPD (Berg and Wright, 2016). The common symptoms and signs are dyspnea with rest or exertion, chronic productive cough, wheezing, flat of the diaphragm, tachypnea, barrel-chest, and tripod position (Dumphy, 2109).
Risk factors are older than 35 years old with history with smoking (Gentry & Gentry,2017). The positive pertinent findings are shortness of breath with activity, intermittent cough but frequent and worse in the AM and productive whitish-yellow phlegm, former smoker (20 pack-year, Also he has RR-20, weight 258 pounds, O2sat 94% on RA. Lungs are clear to auscultation bilaterally with faint forced expiratory wheezes on bilateral bases. The negative pertinent findings are pulse 66, BP 156/94, heart S1 and S2 with no murmurs, and Respirations unlabored.
ICD-10 code is J44.9 Diagnosis Test
Chest x-ray helps to determine the progress of COPD and reveal hyperinflation and helps to rule out other respiratory conditions (GOLD, 2019).
Arterial blood gas provides gas levels to determine (GOLD, 2019).
CBC with differential evaluates the hemoglobin and hematocrit and red blood cell to rule out anemia (Dumphy, 2109).
Medication
Albuterol 90 mcg inhalation Aerosol
2 puffs (180 mcg) every 4 to 6 hours as needed for shortness of breath (GOLD, 2019). Disp 1 = 200 metered inhalation
Refill 0
Albuterol is short-acting beta2-agonists. This is the first line of treatment to treat and manage COPD. SABA relaxes the airway smooth muscle (GOLD, 2019). This medication relieves the acute episodes of bronchospasm (Dumphy, 2019). It is based on the guideline this patient is grading as GOLD B.
Tiotropium 2.5 mcg inhalation
2 puff (5.0 mcg) with the spacer every day (GOLD, 2019). Disp 1 = 60 metered inhalation Refill 0
Tiotropium prevents the effects of acetylcholine, which causes the bronchoconstrictor. This medication is recommended for GOLD grade B for patients with COPD (GOLD, 201). This medication also relaxes the muscle of the airway (GOLD, 2019).
