Chronic Obstructive Pulmonary Disease (COPD)

Purpose

The purpose of this assignment is to apply pulmonary pathophysiological concepts to explain the assessment findings of a patient with respiratory disease. Students will examine all aspects of the patient’s assessment including: Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History (FH), Social History (SH), Review of Systems (ROS), and Medications and then answer the questions that follow on the provided Comprehensive Case Study template.

Activity Learning Outcomes

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

1. Examine the case scenario and analyze the spirometry results to determine the most likely respiratory diagnosis. (CO1)
   Explain the pathophysiology of the respiratory disease. (CO1)
   Differentiate between subjective and objective findings which support the chosen diagnosis. (CO4)
   Apply evidence-based practice guidelines to classify the severity of the respiratory disorder and employ an appropriate treatment plan. (CO1, CO5)

Preparing the Assignment

Requirements

Content Criteria:

1. Read the case study listed below.
2. Refer to the rubric for grading requirements.
3. Utilizing the Week 3 Case Study TemplateLinks to an external site., provide your responses to the case study questions listed below.
4. You must use at least one scholarly reference to provide pathophysiology statements.
5. You must use the current Clinical Practice Guideline (CPG) for the management and prevention of COPD (GOLD Criteria) to answer the classification of severity and treatment recommendation questions. The most current guideline may be found at the following web address: https://goldcopd.org/Links to an external site.. At the website, locate the current year’s CPG and download a personal copy for use. You may also use a medication administration reference such as Epocrates to provide medication names.
6. Proper APA format (in-text citations, reference page, spelling, English language, and grammar) must be used.

Case Study Scenario

Chief Complaint
A.C., is a 61-year old male with complaints of shortness of breath.

History of Present Illness

A.C. was seen in the emergency room 1 week ago for an acute onset of mid-sternal chest pain. The event was preceded with complaints of fatigue and increasing dyspnea for 3 months, for which he did not seek care. He was evaluated by cardiology and underwent a successful and uneventful angioplasty prior to discharge. Despite the intervention, the shortness of breath has not improved. Since starting cardiac rehabilitation, he feels that his breathlessness is worse. The cardiologist has requested that you, his primary care provider, evaluate him for further work-up. Prior to today, his last visit with your practice was 3 years ago when he was seen for acute bronchitis and smoking cessation counseling.

Past Medical History 

• Hypertension
• Hyperlipidemia
• Atherosclerotic coronary artery disease
• Smoker

Family History

• Father deceased of acute coronary syndrome at age 65
• Mother deceased of breast cancer at age 58.
• One sister, alive, who is a 5 year breast cancer survivor.
• One son and one daughter with no significant medical history.

Social History

• 35 pack-year smoking history; he has cut down to one cigarette at bedtime following his cardiac intervention.
• Denies alcohol or recreational drug use

Real estate agent

Allergies

• No Known Drug Allergies

Medications

• Rosuvastatin 20 mg once daily by mouth
• Carvedilol 25 mg twice daily by mouth
• Hydrochlorothiazide 12.5 mg once daily by mouth
• Aspirin 81mg daily by mouth

Review of Systems

• Constitutional: Denies fever, chills or weight loss. + Fatigue.
• HEENT: Denies nasal congestion, rhinorrhea or sore throat.
• Chest: + dyspnea with exertion. Denies productive cough or wheezing. + Dry, nonproductive cough in the AM.
• Heart: Denies chest pain, chest pressure or palpitations.
• Lymph: Denies lymph node swelling.

General Physical Exam  

• Constitutional: Alert and oriented male in no apparent distress.
• Vital Signs: BP-120/84, T-97.9 F, P-62, RR-22, SaO2: 93%
• 180 lbs., Ht. 5’9″

HEENT 

• Eyes: Pupils equal, round and reactive to light and accommodation, normal conjunctiva.
• Ears: Tympanic membranes intact.
• Nose: Bilateral nasal turbinates without redness or swelling. Nares patent.
• Mouth: Oropharynx clear. No mouth lesions. Dentures well-fitting. Oral mucous membranes dry.

Neck/Lymph Nodes 

• Neck supple without JVD.
• No lymphadenopathy, masses or carotid bruits.

Lungs 

• Bilateral breath sounds clear throughout lung fields. + Bilaterally wheezes noted with forced exhalation along with a prolonged expiratory phase. No intercostal retractions.

Heart 

• S1 and S2 regular rate and rhythm, no rubs or murmurs.

Integumentary System 

• Skin cool, pale and dry. Nail beds pink without clubbing.

Chest X-Ray 

• Lungs are hyper-inflated bilaterally with a flattened diaphragm. No effusions or infiltrates.

Spirometry

Title	Predicted	Pre-bronchodilator	% Predicted	Post-bronchodilator	% Predicted	Change
FVC (L)	5.64	5.23	93	5.77	102	9%
FEV1 (L)	4.57	2.92	64	3.01	66	2%
FEV1/FVC (%)	81	56	69	52	64	-5%
TLC	5.5	6.9	125	6.9	125	0%

Case Study Questions

Pathophysiology & Clinical Findings of the Disease

1. Are the spirometry results consistent with obstructive or restrictive pulmonary disease? What is the most likely pulmonary diagnosis for this patient?
2. Explain the pathophysiology associated with the chosen pulmonary disease.
3. Identify at least three subjective findings from the case which support the chosen diagnosis.
4. Identify at least three objective findings from the case which support the chosen diagnosis.

Management of the Disease

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

1. Classify the patient’s disease severity. Is this considered stable or unstable?
2. Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.
3. Describe the mechanism of action for each of the medication classes identified above.
4. Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.

Pathophysiology & Clinical Findings of the Disease

1. The spirometry results indicate both obstructive and restrictive pulmonary disease. The most likely pulmonary diagnosis for this patient is Chronic Obstructive Pulmonary Disease (COPD). The key spirometry findings that support this diagnosis are the reduced FEV1/FVC ratio (below 70%) and the post-bronchodilator FEV1 improvement of less than 12% and less than 200 mL, which is characteristic of obstructive lung diseases like COPD.
2. The pathophysiology of COPD involves chronic inflammation and narrowing of the airways (bronchitis) and destruction of the lung tissue (emphysema). This leads to decreased airflow and lung function. The primary risk factor for COPD is smoking, which causes irritation and damage to the airways and lung tissue.
3. Three subjective findings supporting the COPD diagnosis in this case are: a. Chronic dyspnea that has been present for several months. b. Smoking history of 35 pack-years, which is a significant risk factor for COPD. c. Worsening breathlessness with exertion, which is a common symptom in COPD.
4. Three objective findings supporting the COPD diagnosis are: a. Spirometry results with a reduced FEV1/FVC ratio, which is a hallmark of obstructive lung diseases like COPD. b. Wheezes heard during the lung examination, indicating airflow obstruction. c. Chest X-ray showing hyperinflated lungs and a flattened diaphragm, which are common radiographic findings in COPD.

Management of the Disease

1. To classify the patient’s disease severity, you can refer to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria, which is the recommended guideline for COPD management. Based on the post-bronchodilator FEV1 % predicted value:
   • FEV1 ≥ 80% predicted: GOLD 1 (Mild)
   • FEV1 50-79% predicted: GOLD 2 (Moderate)
   • FEV1 30-49% predicted: GOLD 3 (Severe)
   • FEV1 < 30% predicted: GOLD 4 (Very Severe)

   The patient’s post-bronchodilator FEV1 of 66% suggests moderate COPD.

2. Two “Evidence A” recommended medication classes for COPD are: a. Long-acting beta2-agonists (LABA), e.g., Tiotropium. b. Inhaled corticosteroids (ICS), e.g., Fluticasone.
3. Mechanism of action:
   • LABAs relax the smooth muscles in the airways, leading to bronchodilation.
   • ICS reduce airway inflammation and can help control symptoms and exacerbations in some COPD patients.
4. Two “Evidence A” recommended non-pharmacological treatment options for this patient are: a. Pulmonary rehabilitation program: This involves exercise training, education, and support to improve exercise capacity and quality of life. b. Smoking cessation counseling: Given the patient’s smoking history, quitting smoking is essential to slow disease progression and improve symptoms.