Case Study #1. Additional history questions:

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1 1 Case Study #1 1.) Identify the clinical problem(s) noted in the chief complaint and a brief (one paragraph to one page review of the relevant pathophysiology of the chief complaint). SG presents with a chief complaint of productive cough with dark yellow phlegm and symptoms of wheezing unchanged for a seven week period. The patient verbalizes his cough and wheezing symptoms worsen in the morning time, however his sleep is unaffected by his respiratory changes (denying orthopnea). His symptoms also cause worsening with mild to moderate exercise exertion (ie. stairs and while gardening) and sob only when he coughs. SG denies seasonal allergies, but does feel his cough and wheezing do worsen when he gardens. Even though he is lacking nasal congestion or sneezing symptoms, the literature suggests someone in his age bracket may only present with cough for a diagnosis of asthma. With a history of childhood asthma and a chronic history of smoking for 40 years (whether he quit or not) leads me to believe there may be some underlying lung damage from chronic irritation and inflammation. His symptoms have been stable over the last seven weeks: no one is ill around him, denies sore throat, and no fever indicating there is no acute infection or process at this time. SG verbalizes this is not the first time he has suffered from these symptoms. According to SG, he has gone to the ER six times a year and has been treated with antibiotics and codeine cough suppressant. With this recent exacerbation he has attempted to relieve the symptoms (cough, wheezing, and phlegm) with OTC cough medications and extra water, however has had no relief. SG has not had the flu shot for over two years, making his lungs more vulnerable to infection. He also denies weight loss as associated to the breathing, however he has lost 10 lbs in six months secondary to diet; which may or may not be associated to his respiratory symptoms.his height and weight put him at a BMI of 37.3 which is considered obese. Although research is still ongoing, there has been an association between obesity and chronic lung problems due to excessive fat mass on lung function, exercise capacity, and can ultimately affect prognosis (Franssen, 2008). 2.) Identify any additional assessment data needed to work up the clinical problem(s) identified in the chief complaint. Assessment data will include what you feel needs to be added to the history, physical exam, lab tests, and requests for interprofessional collaboration. Additional history questions: How long did the symptoms last for when you had your persistent cough before you went into the ER those six times? How many years have you had these cough episodes that drove you to go into the ER for treatment?

2 2 Any fatigue? You stated you have been drinking a lot of water. How many glasses per day? Has he had the PNA vaccination? Why did you chose not to get the flu vaccination for the last two years? Do you have any dizziness? Any edema? Any sinus symptoms? Any night sweats? Any loss of appetite? Have your symptoms affected your quality of life? Have you felt depressed? PE: I would want to also assess: HEENT for signs of redness or irritation. JVD although unlikely to be affected for SG, I would still would like to assess ABD palpate abdomen to assess for swelling that may be causing respiratory difficulties Lymph assess for lymphadenopathy Lab Tests: PFT FEV1, FVC, and ratio (index of flow limitations) to diagnose r/o COPD or severity destructive lung process and possible past lung injury secondary to 40 years of smoking and hx of childhood asthma. Spirometry According to American College of Physicians, Spirometry should be obtained to diagnose air obstruction in patients with respiratory symptoms. Chest X Ray r/o CHF, TB, Acute PNA Lung Diffusion Test to assess how well gas exchanges or how well 02/Co2 are transferred between lungs and blood. May suggest emphysema or suggestive of other airway obstructive disorders. EKG r/o cardiac involvement O2 saturation although no cyanosis is noted, it would still be good to assess how well lungs are perfusing.

3 3 ABG (possibly) if saturations low, FEV1 is <50% predicted or acute exacerbation CBC may reveal leukocytosis, anemia, inflammation, eosinophils (possible allergy related), elevated H/H even without respiratory acidosis AAT (Alpha 1 Antitrypsin) deficiency can cause a lack of protection to the lung LFT hepatic congestion Sputum C&S rule out pathogenic bacteria Interprofessional collaboration: I would collaborate with a medical practitioner and request he/she come and assess patient. I would also make a referral to the pulmonologist for further evaluation and workup on this patient s condition. 3.) Identify this patient s diagnosis and differential diagnosis. Diagnosis: Chronic Bronchitis I believe based on the data that patient SG presented with this chronic bronchitis is an undiagnosed and undertreated chronic inflammatory process. With this patient s history of childhood asthma and chronic smoking (of 40 years) patient is at increased risk of having a chronic respiratory illness. As for the history collected from SG we can detect this is would be an ongoing lung destruction process. Based on admission to the ER (at least six times a year) we can also observe there has been repeat infections requiring antibiotic treatment. The literature suggests a diagnosis of chronic bronchitis would consist of the presence of mucus producing cough 3 months a year x 2 years. Based on the lack of questions specific to the length of cough for each exacerbation, it is hard to establish a concrete length of cough producing mucus during the last year. Although he did not specify the length of his past exacerbations he had previously, we can assume that since SG waited 7 weeks till presenting to our clinic it is highly likely he had his symptoms for the 3 months or more. Some research also suggest that an increase amount of episodes of infection and acute bronchitis can lead to chronic bronchitis. Other symptoms associated with chronic bronchitis afflicting SG are constant excessive mucus production, coughing up colored mucus (dark yellow phlegm), and wheezing. Those with bronchitis also have a tendency to have a cough that is worse in the morning and dyspnea with exertion which is also something he is complaining of. Also, SG is more likely to have a diagnosis of chronic bronchitis because of his, age ( >65 more likely to get bronchitis) and frequent of respiratory infections. Allergies such as animal dander and pollen also have an association to chronic bronchitis.

4 4 Differential Diagnosis: Some symptoms that usually are typical symptoms of chronic bronchitis but SG did not exhibit them, these are: chest pain/pressure, tachypnea, and difficulty to breath in AND out. Drinking a lot of water is suppose to thin secretions in chronic bronchitis, but according to SG it did not relieve symptoms.he also did not have any swelling or weight gain, which can also be a symptom of the above assumed diagnosis. However the weight may be an irrelevant assessment tool since he was recently dieting with his wife. COPD I vacillated between chronic bronchitis and COPD because some symptoms seemed to better coincide with one or the other. However there are COPD symptoms that are also usual that SG is not exhibiting: orthopnea, chest tightness, usually nonproductive or difficult to bring up mucus. Also his breathing is not keeping him awake at night and he has no complaints of cough in evenings like can be with a COPD diagnosis. I believe the PFT s will be the key to determining between the two diagnosis s. Other diagnosis s that can not rule out yet: Asthma Wheezing and SOB. However, denies chest pain and frequent coughs are not at night but rather in the morning. Also since atopy symptoms can be associated with chronic bronchitis CHF SG needs more of a cardiac workup to determine if heart is contributing to symptoms Age related deconditioning This may contribute to SG overall status, however this would not account for the excessive mucus secretions Diagnosis s that can most likely r/o based on history obtained: r/o PNA no fever, no chills, no chest pain r/o TB d/t age, worked in an office, retired and leaves home infrequently, lives in what appears to be a somewhat affluent neighborhood, symptoms have been constant over 7 weeks (did not occur gradually), no fever, no chills, no chest pain, no hemoptysis r/o Lung ca no hemoptysis r/o Interstitial Lung Disease Pulmonary arterial hypertension: denies cp, sputum production not common symptom; Pulmonary veno occlusive disease: denies hemoptysis; no symptoms to indicate pulmonary embolism, arterial malformations, or pulmonary edema

5 5 r/o postinfectious cold, post nasal drip, sinusitis usually without phlegm, denies earache, no nasal congestion, no sneezing, no sore throat, no fever r/o Pertussis no one else in home ill at this time. Retired and appears spends more time at home than the average person. 4.) Develop a treatment plan including both pharmacologic and nonpharmacologic interventions, evaluation/follow up strategies, possible interprofessional collaboration, and education plan Before beginning therapy it would be beneficial to Conducting spirometry after bronchodilator treatment which can be a good indicator of how well patient will respond to this standard treatment. 6 minute walk test (6MWT) To establish baseline exercise capacity and track improvement from both therapy and pulmonary rehabilitation Pharmacologic: Pharmacologic starting therapy would be determined based on PFT tests. When starting a therapy it would be important to continue to monitor d/t age, to monitor effectiveness of medications, and make sure correct usage of the MDI. The goal of treatment is to relieve symptoms, slow progression, and prevent further respiratory complications. Acute: Antibiotics during flare ups to reduce the risk of complications However abx should be used with caution because older patients are at risk for resistant bacterial organisms due to overuse of antibiotics previously. Also, an infection can be secondary to viral, bacterial, or atypical organism. In fact an exacerbation from chronic bronchitis is usually triggered by viral diseases. Verifying bacterial infections through the use of sputum cultures would be ideal if a patient is not in acute respiratory distress. Long acting therapy: Bronchodilators to open and relax airways

6 6 Emergency inhalers Albuterol Long term therapy bronchodilators ipratropium (Atrovent) formoterol (Foradil) levalbuterol HCl (Xopenex) salmeterol (Serevent) tiotropium (Spiriva) albuterol sulfate (ProAir, Proventil, Ventolin, AccuNeb Inhalation solution) Inhaled corticosteroids to reduce inflammation. However use of steroids in SG must be used with caution and should considered a treatment later when nothing else works. Steroid use can lead to bone loss and high blood pressure, which is already a problem for SG. fluticasone (Flovent) budesonide (Pulmicort) Combination Inhalers (bronchodilator and a corticosteroid) budesonide formoterol (Symbicort) fluticasone salmeterol (Advair) Whatever inhaled therapy is chosen for SG it is important to consider spacers for maximal therapeutic results. It is estimated that between 28% to 68% of patients do not use metered dose inhalers or dry powder inhalers correctly. (Fromer, 2010) Oxygen therapy SG may need supplemental oxygen if disease progresses or in an acute exacerbation Vaccinations I would encourage SG to get the PNA vaccination (if not already done) and receive his flu vaccination yearly. Nonpharmacologic: Handwashing simple way to prevent introducing an acute infection from the environment into you system. Even something as simple as a cold can severely worsen the symptoms of chronic bronchitis. Pulmonary Rehabilitation Exercise is a key component to rehabilitation of the pulmonary system. By participating is an exercise routine it will strengthen heart, lungs, and muscles. Low impact exercises are ideal, these include walking, swimming, and stationary bike. The intensity should be determined on

7 7 SG s capacity to breath, it is ideal to use dyspnea at the peak for effort. SG should start out at 10 minutes and build up to minutes daily. Nutrition Eating a balanced diet is important in any chronic disease process. For chronic bronchitis add more fruits and green vegetables. Add more fatty acids to help decrease inflammation ie. nuts, cold water fish. Encourage SG to continue high water consumption which will help thin secretions and flush out toxins. Foods high in antioxidants have been thought to decrease acute bronchitis, these include berries, spinach and broccoli. Breathing techniques Teaching SG to use specific breathing techniques will allow for better air exchange, especially with exacerbations. Chest physical therapy (CPT) to loosen mucus in the lungs Sleep adequate rest will help keep SG s immune system strong to fight possible introduced infections Avoid triggers it appears allergens, especially outside activities in his garden, make symptoms worse Avoid crowds Especially during high peak cold and flu season if possible Monitor other body systems Chronic lung disorders can affect other body systems and need to be considered in treatment plan and monitoring. Heart strain, arrhythmias, and eventual heart failure are possible. Osteoporosis for patients who over use steroids for lung therapy needs to be considered. GERD is more common in patients with FEV1<50% and PPI may need to be added. Liver function can also be affected causing hepatic congestion. Systemic inflammation may contribute to anemia which can in turn affect breathing capacity. Musculoskeletal decline or dysfunction from under use because of exercise limitations. Evaluation/follow up strategies: After establishing a new diagnosis and interventions for SG I would want to follow up in 4 6 weeks. I would also like to evaluate if the medications are helping and if adjustments need to be made to improve symptoms. It would also be important to continue education with SG: assessing his understanding of what has already been taught, and introducing new interventions that may improve his quality of life. I would also like to reevaluate his BP which was high during the exacerbation. If his bp is still elevated, I would like to make adjustments to his current bp medication regimen.

8 8 Interprofessional collaboration: I would encouraged SG to follow up with pulmonologist based on his/her recommendations. Education Plan Besides those education interventions state above in nonpharm interventions. I would like to further educate SG on avoiding triggers. While he was in the clinic I would like him to demonstrate the proper use his MDI to make sure he is getting the full benefit of long term treatment. I would follow up with SG on his PNA and Flu vaccination to ward off possible acute exacerbations. Remind SG to uses good handwashing techniques when out in public. Continue teaching SG on diet, exercise, and breathing techniques to better assist him with breathing. Help SG determine a good starting point on an exercise routine (if not already started) making sure to have him gradually progress activity regimen based on breathing status. References Albertson, T., Louie, S., & Chan, A. (2010). The diagnosis and treatment of elderly patients with acute exacerbation of chronic obstructive pulmonary disease and chronic bronchitis. Journal Of The American Geriatrics Society, 58(3),

9 9 American Lung Association. (2012). Chronic Bronchitis.Retrieved from disease/bronchitis chronic/ Asthma and Allergies Foundations of America. (2012). Meter dose Inhalers. Retrieved from: Center for Disease Control. (2012). Chronic bronchitis. Retrieved from: use/uri/bronchitis.html Chronic obstructive pulmonary disease and associated health care resource use north Carolina, 2007 and (2012). MMWR: Morbidity & Mortality Weekly Report, 61: COPD International. (2012). Bronchitis. Retrieved from: international.com/bronchitis.htm Ferrara, A. (2011). Chronic obstructive pulmonary disease. Radiologic Technology, 82(3), Franssen F.M.E., O Donnell D.E., Goossens G.H., Blaak E.E., & Schols A. (2008). Obesity and Lung: 5 Obesity and COPD. Thorax, 63 (12), Fromer, L., Goodwin, E., & Walsh, J. (2010). Customizing inhaled therapy to meet the needs of COPD patients. Postgraduate Medicine, 122(2), doi: /pgm Ghamande, S. A., & Dedhia, H. V. (2011). COPD Management: Look Beyond the Airway Obstruction, Chronic Bronchitis and Emphysema.Current Respiratory Medicine Reviews, 7(1), Lab Tests.(2012). Lab Values. Retrieved from National Heart, Lung, and Blood Institute. (2012). Retrieved from

10 10 topics/topics/copd/ Srinivasan, M., & Shafazand, S. (2012). Chronic obstructive pulmonary disease: a review of nonpharmacologic therapies. Journal Of Clinical Outcomes Management, 19(4), The Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2012). COPD. Retrieved by: