NUR 168 Concepts of Nursing III

Initials: W.P.  DOB 03/18/1953

Age: 67 years old

Race: African American

Gender: male

The patient presents to the office wheeled in a chair by his wife

Patient Scenario:

W.P is a 67-year-old African American male who presented in the office for care with new complaints of multiple acute exacerbations of COPD. He is a chronic smoker (30+ pack-years) and had reportedly lost up to 8+pounds in the last two months.NUR 168 Concepts of Nursing III

Perception: the patient reported that, two weeks ago, he started experiencing SOB (shortness of breath) and fatigue after engaging in minimal activities. He has gradually lost 6-8 pounds in the past two months and minor activities such as walking to the bathroom and back within the house cause extreme tiredness. These symptoms cause sleep disturbance, are aggravated by activity, and have no relieving factors. The symptoms began two months ago and have over time increased in frequency. In the last two weeks, he has not been able to exercise for more than five minutes without fatigue. He perceives that the SOB, smoking, and COPD are emotionally taxing and interfering with his overall health and well-being and ability to perform ADLs.

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Allergies: No known drug, food, or environmental allergies

Medications:

  1. Levothyroxine 50 mcg QD.
  2. Uses 2L of supplemental O2 via nasal cannula (during rest) and 3L after engaging in physical activities.
  3. 70mg Lovenox every 12 hourly(subcutaneous injection)
  4. Daily 10mg prednisone once daily
  5. Combivent-Two- inhalations, four times a day.

Past Medical History (PMH): Severe COPD (Dx: 09/2020) Hypothyroidism, Hemorrhoids external (Dx: 02/2015), hyperlipidemia, and obesity.

Past Surgical History (PSH): No history of minor or major surgeries

Sexual History:

The patient identified as being heterosexual has been married to a spouse for 40 years. Before the spouse (heterosexual), he was in a monogamous relationship with two other sexual partners. He reports no incidences of past or current sexual assault, no libido changes, has sexual intercourse 3-4 times in a week involving anal, vaginal, and oral sex.

Personal/Social History: 

  1. P. is a 67-year-old African American male. He is a high school teacher heading for retirement. The patient has been married for 40 years in a monogamous marriage. He lives in Illinois with his wife and three children; 2 daughters and 1 boy. W.P is a Baptist; he regularly attends church and heads the Children Ministry. He also volunteers three days a month at a local food bank. The patient and his spouse have bi-weekly date nights; attend social gatherings with family and friends twice every month. He admits to taking three bottles of beer every day for 30+ years. He is a chronic tobacco smoker for 30+ pack years. He also uses edible marijuana 2-3 times a month. In the state of Illinois, marijuana is legal. He denies smoking marijuana and denies using other forms of illicit or recreational drugs.

Family History

The patient has three siblings, two brothers ages 48 (PMH of asthma, chronic smoker, and a PSH of Appendectomy 6/1997) and 46 years (Severe COPD and No PSMH) and one sister 50 years old (has a PMH of appendicitis in 2000).NUR 168 Concepts of Nursing III

His mother is 82 years old (alive) with a PMH of HTN and hypothyroidism and a PSH of cholecystectomy.

His father is 86 years old (alive) with a PMH of COPD, chronic smoker, HTN and BPH, and a PSH of Bunionectomy.

His parents have been married for 50 years.

The maternal grandmother is deceased (2010)

The maternal grandfather is 96 years old (living) with gout, asthma, and HTN

The paternal grandmother is deceased (2006)

The paternal grandfather is deceased (2008)

His daughters are 38 & 35 y/o no PSH or PMH and son 32 y/o with asthma and No PSH.

Immunization: Up to date on all vaccinations.  Annual Flu shot in October 2020.

REVIEW OF SYSTEM (ROS):

General: the patient presented in the office wheeled in a chair by his wife. He had a tired appearance, a hoarse voice, and smoke-odored clothing. He was diagnosed with COPD   two months ago. On presentation, he denied nocturnal SOB, recent chills, sore throat, and fever, but admitted to having a worsening productive cough (mucoid). Before the onset of a cough, he had night sweats with wheezing, dyspnea, and fatigue. Over the last two months, he has had a decreased appetite and has gradually lost up to 8 pounds. This is the largest weight loss for over 10 years. He also experiences shortness of breath and increased fatigue even with minimal exercise. He reports frequent cravings to smoke tobacco and thus smokes up to 20 cigars in a single day.  These symptoms cause sleep disturbance and interfere with his emotional and physical well- being causing an inability to perform activities of daily life (ADLs). Normally, the patient engages in routine physical exercise that primarily comprises of Zumba, low impact cardio, and cycling classes 4-5 days a week. However, the current symptoms prevent him from engaging in these exercises. The patient acknowledges home life as good and denies any safety issues, abuse or fears sustained at home.

Integumentary/Skin: patient denies having open sores or wounds on the lower and upper trunk or extremities. Declines having any recent rashes but admit to having acne breakouts on the back. The patient admits to having skin that is flaky and drier than usual, brittle, and stained fingernails. He admits to having excessive sweating in the palms of feet and hands, and armpits.

HEENT: the patient denies dizziness, headache, or head trauma. He is long sighted thus requires corrective lenses for both eyes, denies loss of peripheral or central vision. The last eye exam was six months ago. The patient denies hearing loss, pain, or ringing in the ears.  He denies abnormal ear discharge. He denies gums, cheeks, and tongue sores or ulcerations. The patient denies difficulty closing or opening the jaw, swallowing, hoarseness, or loss of taste. He smokes approximately 20 cigarettes a day. He smokes the first cigarette within the first 30 minutes after waking up.  He started smoking at 40 years old and has smoked for 30 years. Potential smoking triggers include stress (work-related), work breaks (to make social connections), alcohol intake (daily), driving, anxiety, anger, frustration, and depression. He has had previous unsuccessful quit attempts when he experienced symptoms of insomnia, cravings restlessness, and irritability. He flosses and brushes teeth 2-3 times a day using fluoride-free paste. Has lost three teeth, has stained teeth and gums. He denies bleeding gums. His last dental exam was four months ago. The patient denies loss of smell, nasal discharge, and recurrent nose bleeding.NUR 168 Concepts of Nursing III

Neck: the patient denies any swelling or lumps in the neck, he denies pain with movement.

Cardiovascular/Peripheral Vascular: the patient admits intermittent mild chest pains. Denies swelling of the face and upper extremities has mild swelling of lower extremities, denies palpitations. Denies having a history of murmurs, denies orthopnea, denies paroxysmal nocturnal dyspnea and admits having physical activity limitations.

Respiratory:  the patient admits to having SOB, dyspnea, productive cough with purulent sputum, and wheezing. He denies nocturnal SOB, denies exposure to influenza and TB, receives annual influenza vaccination and the last vaccination was on 10/2020. The patient reports that he was diagnosed with COPD two months ago. Before the diagnosis, he had recurrent respiratory infections. He is a chronic tobacco smoker. He has smoked for 30+pack years.

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Gastrointestinal: the patient denies vomiting, diarrhea, or nausea.  He admits to having constipation occasionally based on his dietary intake (constipation is common with carbohydrates such as bread and pasta). The color of the stool is light brown to soft. He has no difficulties in passing stool. He denies having clay-colored sticky black or tarry stools. He denies blood in the stool. Has a decreased appetite in the last two months, and has lost up to 8 pounds within the last two months.

Musculoskeletal: the patient denies swelling or pain in the lower and upper extremities, joints, and neck. He is unable to engage in physical activity or perform routine ADLs due to increased fatigue. Every time he rides in the car he uses seat belts. He denies having problems with ROM in the hands and large joints.

Psychiatric: the patient admits that the increased fatigue, SOB, prior COPD diagnosis have influenced a new set of emotional disturbance and increased worry. He denies auditory or visual disturbances, denies self-harm and suicidal ideations.NUR 168 Concepts of Nursing III

Neurologic: The patient denies fainting or dizziness. He denies loss of memory, headaches, loss of consciousness (LOC), movement seizures, involuntary muscle spasms, tingling, and numbness in the lower and upper extremities.

Endocrine: the patient has a history of hypothyroidism and takes 50 mcg of Levothyroxine. He denies having cracked skin, skin flaky, and dry on both lower and upper extremities.

Allergic/immunologic: Patient denies allergies to medication, food, or environmental.

OBJECTIVE DATA

General:  Patient is A&O x4, moderately obese, and tachypnoiec

VS: Temp: 370c, BP- 126/73, HR-72 (apical), RR-28, O2 sat-90% under nasal prong O2 3L/min., Height- 5’8” Weight-204 lbs. (BMI 31.0 = obesity). Patient denies any discomfort or pain.

General Appearance: The patient is A&Ox4, appears acutely ill, and tachypnoiec.

HEENT

Head: Normocephalic and atraumatic, no lesion bruising, no masses, lesions bruising. No tenderness on palpating the maxillary and frontal sinuses.

Eyes: No crusting, exudates, or lesions of the eyelashes and eyelids. PERRLA. No exophthalmos, periorbital edema, or enophthalmos. With contact corrective lenses, vision is 20/30 for hyperopia. The retina is bilaterally intact. No bilateral lens cataracts, or intraocular bleeding.

Ears: hearing is intact bilaterally, no pain with pushing on the tragus or pinna movement. Inner and outer ear structures have no discharge, swelling, or redness. Bilaterally, the tympanic membrane is shiny, gray, with an intact cone reflection present at 7 o’clock on left and 5 o’clock on right. There is excess dark brown and soft cerumen. No exudates, inflammation, or fluid around the inner ear and tympanic membrane. Bilateral hearing intact for low, medium, and high pitches.

Nose/Mouth/Throat: moist and pink mucous membranes, no bleeding. No evidence of turbinate bruising, bleeding, or swelling. The septum is midline but the cricosternal distance is 2 fingers (decreased). There are no sores, wounds, or exudates on the tongue, gums, and cheeks. He has brown stained teeth, loss of one lower canine, and two upper incisors. No halitosis, no pain in chewing (the author requested the patient to stimulate chewing). On palpation and percussion of the jawline, there is no pain.NUR 168 Concepts of Nursing III

 Neck/Lymph: supple and soft, no trachea swelling or deviation, symmetrical thyroid, with no masses, goiter, or lumps. On palpation, there is no tenderness or lymphadenopathy beyond the axillae. It is non-tender on left to right hyperflexion and hyperextension. JVP- was mildly elevated (3.5 cm above the sternal angle), no carotid bruit.

Cardiovascular/Peripheral Vascular: mild pedal edema, no facial edema. No flapping tremors or peripheral cyanosis on inspecting the hands. No muscle wasting, finger clubbing, or palmar erythema. The patient has nicotine stains. On auscultation, normal S1 and S2 were heard. No rubs, no murmurs or gallop rhythm, the heart rate is 72bpm regular, +2brachial, pedal, radial, and femoral pulses. Displaced apex beat. HR normally elevated with activity and returns to the baseline with rest. The color of the feet, hands, and lips is normal for ethnicity.

Respiratory: on inspection, the patient had a barrel-shaped chest due to an increase in the anterior-posterior diameter. The chest moves symmetrically with respiration with occasional use of accessory muscles. No deformities of the chest wall. On palpation, there is a decrease in the bilateral chest expansion but the tactile fremitus was the same. On percussion, bilateral lungs are hyper resonant with no cardiac and liver dullness. Patient has vesicular breath sounds on auscultation, a general expiratory rhonchi, and fine lung base inspiratory crepitation’s.

Gastrointestinal: the abdomen is non-tender, non-distended, and soft, with no lumps, protruding tumors, or masses that were felt with percussion and palpation. The abdominal girth is 44. The skin is dry, with no wounds or rashes. The umbilicus is inverted, dry, and clean with no discharge. The overall skin color and tone is consistent with the patient’s ethnicity and race. Active and present bowel sounds in all 4 abdominal quadrants. At MacBurnie’s point, there is no rebound tenderness and Aaron’s sign is negative. The liver spans 10.8 cm and dull on percussion and non-palpable.

Rectal: moist and pink anus, the anal sphincter has a good tone, no fissures, no hemorrhoids discharge, or masses. On internal exam, no lumps or masses palpated.

Musculoskeletal/Peripheral Vascular: mild pitting edema of the lower extremities. The patient can differentiate between light, sharp, and dull touch on both lower and upper extremities. The toes and fingers have a normal color for race and ethnicity. There is symmetrical development of muscles on the lower and upper extremities. The patient has equal grips and strengths, good tone, FROM in all joints. No crepitus, tenderness, inflammation, or edema. In all groups, muscle strength is 5/5. No coordination or balance deficits. The patient can maintain balance with closed eyes. No spinal curvature, kyphosis, and scoliosis. The patient has an upright posture, equal bilateral shoulder strength, full AROM, and ROM. NUR 168 Concepts of Nursing III

Neurologic:  A&O x4 to person, place, and time. He can follow both simple and complex commands. He can recall incidences and events of the last three days. The patient can recite a sequence of five words back in a given order. He has intact depth perception. Grossly intact cranial nerves II –XI and deep tendon reflexes intact. The patient can differentiate hard, soft, sharp, and blunt sensations on the lower and upper extremities, as well as cold and hot temperatures.

Diagnostic Tests:

  1. CBC with Differentials R68.89- Lymphocytes 6800 (cells/uL) and WBC of 20.1 (1,000/uL) elevated)
  2. Thyroid Panel with TSH R94.6-3.8 mIU/L
  3. Lipid panel E78.5- AST 33 U/L, and ALT 30 U/L(hypercholesterolemia)
  4.  Spirometry- FEV1 to FVC ratio of 55% (decreased; the normal ratio is 70%)
  5. Chest X-ray-cardiomegaly, bilateral bullae, hyperinflation with slight flattening of the diaphragm.
  6. Arterial blood gas (ABG) – 93% O2 Saturation, PaCO2 at 47mmHg (elevated to indicate hypercapnia).

Assessment 

Primary Diagnosis

Acute Exacerbation of COPD due to the smoking-the patient had previously been diagnosed with COPD two months before presentation. The symptoms of dyspnea, a productive cough (mucoid sputum), and reduced tolerance to physical activity are primary symptoms of COPD (Mathioudakis et al, 2020). The latter happens when the metabolic requirements of physical activity require high pulmonary ventilation levels. The patient’s history as a chronic smoker is also a significant risk factor for COPD. According to Mathioudakis et al (2020), the physical examination findings of a barrel and hyper-inflated chest, expiratory rhonchi and vesicular breathe sounds, and diagnostic findings of a decreased FEV1 to FVC ratio of 55%, 93% O2 Saturation, PaCO2 at 47mmHg, and elevated WBCs are also indicative of COPD.  During the presentation, the severity of SOB increased even with rest. SOB was associated with wheezing and gradual worsening of symptoms suggests that it was an acute exacerbation of COPD. In this patient’s case, the most likely trigger of the exacerbation was smoking.

Differential Diagnoses

Bronchiectasis

Patients who are diagnosed with bronchiectasis present with a history of a chronic productive cough. However, the amounts of sputum produced are copious and purulent. In other cases, patients might have a history of persistent SOB, wheezing and a decreased tolerance to exercise or physical activity (Smith, 2017).  However, this is a less likely diagnosis since the sputum produced by the patient was mucoid and not purulent as it typically occurs in bronchiectasis. Besides, it was not foul-smelling and in huge amounts. The physical exam findings revealed fine crepitations. However, patients with bronchiectasis have coarse crepitations (Smith, 2017). Besides, W.P had no evidence of finger clubbing and the chest x-ray had no signs of cystic shadows or thick bronchial walls.NUR 168 Concepts of Nursing III

Congestive Heart Failure

Mr. W.P. may have primarily developed congestive heart failure or it could be a complication of chronic lung disease (COPD). The patient has a history of decreased tolerance to physical activity, presented with increased dyspnea and wheezing. On physical exam, he had a mildly raised JVP (3.5 cm), there were crepitations on bilateral lung bases with fine crepitations, mild pitting pedal edema, and cardiomegaly on chest x-ray. According to Martindale et al (2016), these are all signs of heart failure.  However, since this patient’s history does not have a primary cause that can result in heart failure such as hypertension,   a defect of a cardiac valve, or ischemic heart disease, it is a less likely diagnosis in this case. To rule out heart failure, it will be necessary to order for an ECG.

References

Mathioudakis, A. G., Janssens, W., Sivapalan, P., Singanayagam, A., Dransfield, M. T., Jensen, J. U. S., & Vestbo, J. (2020). Acute exacerbations of chronic obstructive pulmonary disease: in search of diagnostic biomarkers and treatable traits. Thorax, 75(6), 520-527.

Martindale, J. L., Wakai, A., Collins, S. P., Levy, P. D., Diercks, D., Hiestand, B. C., … & Sinert, R. (2016). Diagnosing acute heart failure in the emergency department: a systematic review and meta‐analysis. Academic emergency medicine, 23(3), 223-242.

Smith M. P. (2017). Diagnosis and management of bronchiectasis. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 189(24), E828–E835. https://doi.org/10.1503/cmaj.160830 NUR 168 Concepts of Nursing III