respiratory issues
Discussion #1
There are several questions I would ask Mr. Barley regarding his history surrounding his respiratory issues. At what point in his farming career did he start wearing protection from the chemicals he uses? Did he always work on a farm? Has he ever works around any other pollutant, asbestos? How long has this shortness of breath upon exertion been happening? Is he around others smoking in the household? Does he smoke in a well ventilated area or within his home or car with the windows up? I would ask if his family had any respiratory problems, smoked, or had any lung cancer associations and at what age. COPD tends to be a smoker’s disease that runs in families and appears in advanced age (Buttaro et al., 2017). Has he been treated for any other lung issues in the past?
I don’t think I would have done any diagnostic tests differently since pulmonary function tests are the gold standard for diagnosing COPD. I would have also suggested a chest xray to rule out any other probable causes to Mr. Barley’s shortness of breath. Although now I see that is not indicative of diagnosing COPD, it could rule out other differential diagnoses. In my physical exam I would have auscultated the lungs carefully, and assessed for pursed lip breathing or tripod positioning since Mr. Barley was noted to be slightly short of breath in the exam room.
Mr. Barley should be given extensive education on the importance of smoking cessation. The follow up visit should include pulmonary mechanics once again to assess if there has been any regressions or improvements. He should be prescribed an inhaler like albuterol which will help dilate the bronchioles and allow for easier movement of air in the airways. The patient should also be educated on pursed lip breathing and diaphragmatic breathing exercises. These exercises can help the patient with COPD manage breathlessness (Mendes et al., 2019).
Discussion #2
Mr. Barley is a 58-year old man who presents to the office today with a chief complaint of worsening productive cough and shortness of breath for the past 2 weeks. Patient states that although his current symptoms have lasted for two weeks, he has noticed that for the last two years, the symptoms are more prevalent during the winter season. The patient reports when he coughs, whitish phlegm is produced. He also reports shortness of breath on exertion; such as, walking up two flights of stairs. The patient denies chest pain, fevers, weight loss, recent travel, orthopnea, swelling in his extremities, recent travels out of the country, tuberculosis or chemical exposure. Mr. Barley reports smoking a half of pack of cigarettes a day, which he states is down from a total of one to two pack of cigarettes a day for the last 26 years. Mr. Barley is married and has been with his spouse for 35 years and have two healthy children. Mr. Barley states his mother is alive and has hypertension; however, his father passed away from a stroke. He reports no family history of diabetes, lung disease, colon cancer or liver disease. Mr. Barley states he is a farmer, and although he works on a farm he denies being exposed to any dusts or chemicals due to wearing protective clothing and raising crops organically.
Although obtaining a detailed HPI can narrow down differential diagnosis, completion of an in depth physical examination and utilizing appropriate diagnostic tools are appropriate in identifying any abnormalities that may confirm or disapprove a diagnosis. Initially, I will obtain a complete set of vital signs including pulse oximetry. Pulse oximetry must be included with the set of vital signs to determine the patient’s arterial oxygen saturation level (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook, 2017). Then a general head to toe assessment is needed to assess for any abnormalities. For patients with dyspnea, observing their body position and their breathing pattern can provide you with important clues of the severity of the disease (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook, 2017). Although a complete head-to-assessment will be completed, I will mainly focus on the respiratory and cardiac assessment. For respiratory, I would use my stethoscope to listen to both posterior and anterior lung sounds. When assessing lung sounds, I am listening for any abnormal breath sounds; such as, inspiratory or expiratory wheezing and prolonged expirations (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook, 2017). For the cardiac assessment, I would check the patients pulse and assess for an irregular rate and rhythm. I would also listen to heart sounds and assess for jugular vein distention, peripheral edema, and pulses in the lower extremities. For COPD, the gold standard diagnostic tool is the spirometry test. The spirometry test is able to measure airflow limitations. Through forced expiratory volume in 1 second and forced volume capacity (FEV1/FVC) the ratio of the two are used for diagnosis. The presence of a post bronchodilator FEV1/FVC of lest than .70 confirms airflow limitation (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook, 2017)). Another test I would have liked to be completed is obtaining a chest radiograph. Although chest radiographs are not needed for the diagnosis for COPD, given the patients occupation and history of smoking, I would have wanted to rule out lung cancer or other diagnosis.
Mr. Barley’s plan of care will include discussing his new diagnosis of COPD, new medication regimen (albuterol and tiotropium), avoidance of exacerbation and discussing smoking cessation. I would also reiterate that there is no cure for COPD; however, symptoms can be controlled with medication adherence and smoking cessation. I would also encourage Mr. Barley to contact me if he starts to feel sad or depressed due to the risk of COPD limiting his activities do daily living. For medications, Mr. Barley will be started on Albuterol which is a short acting inhaler that is only to be used as a rescue inhaler. A long acting inhaled bronchodilator, such as, Spiriva (tiotropium) will also be prescribed. I will educate the patient that spiriva is to be used daily. After instructions have been provided, I will incorporate the teach back method to ensure the patient fully understand the instructions that were provided. Discussion of smoking cessation will also be discussed and the benefits it can have on his recent disease diagnosis. We will discuss the importance of regular follow up visits for the PFT test to be performed every 6 months to monitor the effectiveness and progress of Mr. Barley’s condition. Patient education will also include signs and symptoms to look out for that require emergency medical attention; such as: chest tightness, rapid heartbeat, cyanosis of the lips, unable to catch the breath even with the use of the prescribed medications and fever (Chessman, N.D.).
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