Elizabeth Varona-Martin

Module 7

We finished our final clinical hours this week. While our course curriculum prepares us for further study and skill development, the clinical experience has provided us with a great understanding of what it is like to work as an Advanced Registered Nurse Practitioner. The clinical experience has allowed us to practice and demonstrate the skills we’ve learned with actual patients. While we are eager to start the next phase of our journey, we are also aware that we still have much to learn.

One of the patients I had the opportunity to work with was a 74-year-old white male with a known history of COPD. He complains of increased respiratory difficulties. According to his symptoms, he has chest congestion with a wet cough and is expectorating yellow phlegm. He experiences wheezing and shortness of breath. The symptoms are moderate severity and occur at regular intervals, following a predictable pattern. Associated symptoms consist of fatigue, and he has a low-grade fever. He hasn’t been in contact with anyone sick. He is fully vaccinated, including the Influenza and the COVID 19 vaccine. 

Past Medical History : COPD, Benign hypertension, CAD (coronary artery disease), 

Hyperlipidemia, and OSA (obstructive sleep apnea).

Medications: 

Quinapril 5 mg 1 tab by mouth daily

Advair 250/50 Use 1 inhalation 2 times each day

Ventolin HFA inhalation aerosol 90 mcg 1 puff PRN q 4-6 hrs

Rosuvastatin 10 mg tab by mouth daily

Aspirin 81 mg 1 tab by mouth daily

Physical exam:

Respiratory system: rhonchi , scattered wheezes

Cardiovascular system:  Regular rhythm, No gallop, SM. No edema 

The differential diagnosis is extensive among individuals who arrive with dyspnea, cough, and sputum production in their middle or later years, including COPD, heart failure, interstitial lung disease, and thromboembolic disease.

Impression and Plan

Diagnosis

ICD10-CM J44.9- COPD

ICD10-CM J40.Bronchitis 

Plan

COPD with acute exacerbation. Patient was encouraged to maintain good hydration. 

Start Prednisone 40 mg po daily with food x 5 days

Z pack  250 mg daily by mouth x 5 days, 

Ventolin HFA inhalation aerosol 90 mcg 1 puff PRN q 4-6 hrs  for wheezing and SOB

Tessalon perles as needed for cough.

We encouraged the patient to participate in a pulmonary rehabilitation program. Physical exercise (exercising for 30 minutes twice a week at a level that induces mild shortness of breath) may minimize hospitalizations for COPD exacerbations.

Stopping smoking is the first and most critical step in any COPD treatment regimen. This is true regardless of how far the condition has progressed. Stopping smoking, regardless of how long they’ve had COPD, can help halt its progression.

Learning about COPD is a valuable lesson, essential in our development as healthcare providers. Diagnosing COPD correctly is critical because effective treatment can reduce symptoms, particularly dyspnea, reduce the frequency and severity of exacerbations, improve health, increase exercise capacity, and extend life. Respiratory symptoms should not be attributed to COPD without proper evaluation and diagnosis because current and past smokers are also at risk for various other medical issues with completely different treatments (King Han et al., 2022).

In all patients who report any combination of dyspnea, chronic cough, or chronic sputum production, the diagnosis of COPD should be considered. The spirometry test should be performed before and after bronchodilator administration, especially if there is a history of exposure to COPD triggers such as tobacco smoke, occupational dust, indoor biomass smoke, a family history of chronic lung disease, or the presence of associated comorbidities (Stoller, 2022).

All patients experiencing a COPD exacerbation should be given inhaled short-acting bronchodilator treatment (Grade 1B). Short-acting beta-adrenergic agonists (SABA) such as albuterol and levalbuterol have a faster action start than ipratropium. Therefore a SAMA-SABA combination or SABA alone is recommended over ipratropium monotherapy (Stoller, 2022).

References

King Han, M., Dransfield, M. T., & Martinez, F. J. (2022, March 18). Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging. UpToDate. Retrieved April 26, 2022, from https://www.uptodate.com/contents/chronic-obstruct… 

Stoller, J. K. (2022, March 18). COPD exacerbations: Management. UpToDate. Retrieved April 26, 2022, from https://www.uptodate.com/contents/copd-exacerbations-management?search=copd+exacerbation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.