Plan for Follow-up Care

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Discussion Content

  1. For the Respiratory topic, please read the following clinical case scenario:
    ____
    SUBJECTIVE:
    Janis, a 59 – year – old female, presents with tachypnea, dyspnea on exertion, and mild chest discomfort. She was diagnosed with emphysema four years ago and was placed on bronchodilator therapy. She has an 80-pack-year history of smoking. “ I feel short of breath when I walk, and my chest is sore. ” She describes her chest soreness as mild pressure, rated as two on a 1 – 10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing hard. She states that she has had a nonproductive cough for four days and feels more fatigued than usual.

    Past medical history: She has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had two exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully.
    Family history: Noncontributory.
    Social history: She lives with her husband, who also smokes two packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.
    Medications: Albuterol MDI, 90 mcg/inhalation, two puffs as needed every 4 – 6 hours; ipratropium bromide MDI, 18 mcg/inhalation, two puffs four times/day; ibuprofen as needed for arthritic pain.
    Allergies: Janis is allergic to Keflex and penicillin.

    OBJECTIVE:
    General: Janis is dyspneic at rest, sitting. The use of accessory muscles is evident. Pursed lip breathing noted.
    Vital signs: BP: 122/64; P: 92; R: 26; T: 100.2; SpO2: 88. AP to transverse ratio is 1:1.
    Skin: Warm and dry.
    HEENT: Negative.
    Cardiovascular: RRR: S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2 + /4 + .
    Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on the right and left anterior and lateral thorax from the 2nd to 5th intercostal spaces. PFT conducted two months prior to the visit showed obstructive flow patterns and reduced FEV1/FVC.
    Abdomen: Soft, with bowel sounds; tympanic to percussion.
    Neurologic: Negative.

    Based on the described case scenario, please answer the following questions:

    1. -Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
    2. -What is the most likely differential diagnosis, and why?
    3. -What is your plan of treatment?
    4. -What is your plan for follow-up care?
    5. -Are any referrals needed?
    6. -What are additional risk factors evident for this patient?
    7. -Are there any standardized guidelines that you should use to treat this patient?
    8. DQ Submission requirements:
    • The submitted paper should be according to current APA7 guidelines.
    • Must utilize credible data sources such as CINAHL, MEDLINE, Embase, Clinical Key, and Cochrane Library (Accessed from the library page at the fnu.edu website).
    • FNU Librarians are available to assist each student with retrieving the required scholarly content.
    • Two or more scholarly sources must be utilized.
    • All sources must have been published within the last five years.
    • All article sources must be cited.
    • Two responses to your classmates

plan for follow-up care

Based on the clinical case scenario provided, here are the answers to your questions:

  1. Diagnostic or Imaging Studies:
    • Chest X-ray or CT scan: These imaging studies can help confirm the diagnosis and assess the extent of lung involvement, including the presence of emphysema, any new infiltrates, or pleural effusions.
    • Arterial blood gas (ABG) analysis: This can provide information about the patient’s oxygen and carbon dioxide levels, helping to evaluate the severity of respiratory distress.
    • Pulmonary function tests (PFTs): Although the patient had PFTs conducted two months prior, it may be necessary to repeat these tests to assess the current lung function and confirm the obstructive pattern.
    • ECG (Electrocardiogram): To rule out cardiac issues as a cause of chest discomfort and tachypnea.
  2. Most Likely Differential Diagnosis: The most likely differential diagnosis for this patient includes:
    • Acute exacerbation of chronic obstructive pulmonary disease (COPD) due to the worsening of her dyspnea, cough, and chest discomfort, along with the presence of wheezing and crackles on examination.
    • Pneumonia, as she has a productive cough and fever.
    • Cardiac issues such as angina or myocardial infarction due to chest discomfort, although the absence of significant findings on cardiovascular examination makes this less likely.
  3. Plan of Treatment:
    • Oxygen therapy to maintain oxygen saturation above 90%.
    • Bronchodilators (Albuterol and ipratropium bromide) to relieve bronchospasm.
    • Antibiotics if pneumonia is suspected.
    • Pain management for chest discomfort, considering the patient’s allergy to Keflex and penicillin.
    • Smoking cessation counseling and support.
    • Pulmonary rehabilitation referral to improve lung function and quality of life.
  4. Plan for Follow-up Care:
    • Monitor vital signs, oxygen saturation, and symptom improvement.
    • Repeat PFTs to assess lung function and response to treatment.
    • Regular follow-up appointments to assess smoking cessation progress, medication management, and overall health.
  5. Referrals Needed:
    • Referral to a pulmonologist for further evaluation and management of COPD.
    • Consider referral to a cardiologist if cardiac issues are suspected or if symptoms persist despite pulmonary treatment.
  6. Additional Risk Factors Evident:
    • Heavy smoking history (80-pack-year) is a significant risk factor for COPD and lung disease.
    • Ongoing exposure to secondhand smoke from her husband.
    • Previous exacerbations of COPD.
  7. Standardized Guidelines:
    • The GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines provide recommendations for the diagnosis and management of COPD.
    • ATS/ERS (American Thoracic Society/European Respiratory Society) guidelines can also be referenced for COPD management and pulmonary function testing.
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