NUR 611 Discussion 2 Case 2

Sample Answer

A 72-year-old male presents to the clinic with a four-week history of persistent productive cough nonresponsive to normal cough medication. He also reports experiencing chest pain while coughing and noticing dark-colored blood on his tissue. He has a ten-year history of diagnosed chronic obstructive pulmonary disease (COPD) and a 45-year history of two packs a day cigarette smoking.

However, he states he quit smoking about six years ago due to financial constraints. His vital signs include BP 137/90, HR 82, RR 22, and a BMI of 23. Taking note of the already diagnosed COPD, it is crucial to ask the patient if there were any previously prescribed medications, medications he is on, and whether he is compliant with them. It is also important to further inquire about his cough, whether it has worsened during the four weeks, and if he has experienced any fever or chills.

Additionally, one may ask the patient whether he has been experiencing dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral limb edema, and confusion that may indicate the development of corpulmonale (Roberts et al., 2023). When examining the patient, I would look for central cyanosis, jugular vein distension, lip pursing, finger clubbing, and edema. I would also do a chest examination to inspect for a barrel chest, palpate to check for cardiomegaly, percuss for hyper-resonant or dull lung sounds, and auscultate for wheezing or crackles.

My differential diagnosis for this presentation would be a COPD cough, lung cancer, and bacterial pneumonia. Bacterial pneumonia is a common complication of COPD, while lung cancer may develop due to the previous prolonged history of smoking (Szalontai et al., 2021). As a result, I would request a chest radiograph and computerized tomography to check any parenchymal changes, tumors, infection, and fluid accumulation in the alveoli and pleural cavity. I would also perform spirometry for lung function testing.

I would also request a sputum sample for microscopy, culture, sensitivity, and cytology to look for any bacterial or malignant cells. I would also do a complete blood count to check for leukocytosis and eosinophil counts.
Important medications required for this patient include antibiotics, inhaled bronchodilators, and corticosteroids. Amoxicillin-clavulanic acid and azithromycin are the two suitable medications used to treat pneumonia. I advise the patient that he is likely to experience gastrointestinal discomfort such as nausea, vomiting, and diarrhea and risk of hepatotoxicity with the use of these medications.

On the other hand, I would prescribe salmeterol, ipratropium, and fluticasone inhalation medications, two puffs as needed when the patient is experiencing any exacerbation (Yang et al., 2021). For maintenance therapy, I would prescribe formoterol, tiotropium, and fluticasone inhalation medication in two puffs twice daily. However, I would inform the patient of the risks of palpitations and tremors due to hypokalemia due to the use of beta-agonists such as salmeterol and formoterol.

I would also inform the patient of the risk of developing oral candidiasis and respiratory infections due to using fluticasone. As a result, I would request liver function tests and serum electrolyte levels to help monitor the drug’s side effects. I would also refer the patient to a pulmonologist for COPD follow-up or an oncologist if lung cancer is confirmed.

References

• Roberts, M., Smith, T., Wheatley, J., & Cho, G. (2023). Symptom Burden of Patients with Chronic Obstructive Pulmonary Disease Attending the Westmead Breathlessness Service Prevalence, Associations, and Sex-Related Differences. International Journal of Chronic Obstructive Pulmonary Disease, 18, 2825-2837. https //doi.org/10.2147/COPD.S433541
• Szalontai, K., Gémes, N., Furák, J., Varga, T., Neuperger, P., Balog, J. Á., Puskás, L. G., &Szebeni, G. J. (2021). Chronic Obstructive Pulmonary Disease Epidemiology, Biomarkers, and Paving the Way to Lung Cancer. Journal of Clinical Medicine, 10(13). https //doi.org/10.3390/jcm10132889
• Yawn, B. P., Mintz, M. L.,& Doherty, D. E. (2021). GOLD in Practice Chronic Obstructive Pulmonary Disease Treatment and Management in the Primary Care Setting. International Journal of Chronic Obstructive Pulmonary Disease, 16, 289-299. https //doi.org/10.2147/COPD.S222664