Case Scenario-A 61-year-old Male with Complaints of Shortness of Breath

Case Scenario-A 61-year-old Male with Complaints of Shortness of Breath

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1. Are the spirometry results consistent with obstructive or restrictive pulmonary disease? What is the most likely pulmonary diagnosis for this patient?

The patient’s spirometry results are harmonious with obstructive pulmonary disease. This is evidenced by a forced expiratory volume in the first second (FEV1) of less than 80 percent of the predicted value (64 percent), a lower forced vital capacity (FVC), and an FEV1: FVC ratio of less than 0.7 (0.56).

The patient’s diagnosis is chronic obstructive pulmonary disease (COPD). This is evidenced by insignificant changes in the spirometry readings of the FEV1/FVC ratio after administering a bronchodilator (Celli & Wedzicha, 2019).

2. Explain the pathophysiology associated with the chosen pulmonary disease.

COPD manifests with limitation of airflow, impaired gaseous exchange, excessive mucus secretion, and pulmonary hypertension. Notably, limited airflow is caused by perpetual inflammation, exudation, and fibrosis (Celli & Wedzicha, 2019). This leads to a decrease in the FEV1 and a subsequent decline in the FEV1: FVC ratio (Celli & Wedzicha, 2019). Also, limited airflow leads to the retention of inhaled air and increases the risk of hypercapnia (Celli & Wedzicha, 2019). This triggers hyperinflation. Inflammation associated with COPD is attributed to oxidative stress and proteases (Stockley et al., 2019). Proteases mediate the breakdown of elastin and predispose an individual to emphysema and airway inflammation (Stockley et al., 2019). Findings demonstrate that oxidative stress is exacerbated in patients with COPD. Excessive mucus secretion results from increased goblet cells and enlargement of submucosal glands due to persistent airway inflammation (Stockley et al., 2019). Other mediators, such as proteases, may increase mucous secretion by activating the epidermal growth factor (Stockley et al., 2019). Pulmonary hypertension represents a poor prognosis of COPD; it is triggered by vasoconstrictor pulmonary arteries secondary to hypoxia. Both viral and bacterial respiratory infections worsen COPD.

COPD occurs in two forms: chronic bronchitis (CB) and emphysema. CB is caused by the destruction of the endothelium and compromised mucociliary clearance (Celli & Wedzicha, 2019). This leads to the accumulation of mucus, bacteria, and neutrophils. A continuous inflammatory response leads to fibrosis via hyperplasia and metaplasia of goblet cells (Celli & Wedzicha, 2019). The structural changes limit gaseous exchange. On the other hand, emphysema is characterized by enlarged airspaces and a decrease in the volume of the air sacs. The destruction of alveoli impairs elastic recoil and gaseous exchange (Celli & Wedzicha, 2019). It also constricts the airways and compounds impaired gaseous exchange.

3. Identify at least three subjective findings from the case that support the chosen diagnosis.

Evaluation of the patient revealed a nonproductive cough in the morning, shortness of breath on exertion, and fatigue. According to the patient, his fatigue and shortness of breath have worsened over the past three months. These findings are suggestive of chronic obstructive pulmonary disease.

4. Identify at least three objective findings from the case that support the chosen diagnosis.

Firstly, a chest x-ray revealed hyper-inflated lungs and a bilaterally flattened diaphragm. Hyperinflation occurs due to limited airflow, which leads to the retention of inhaled air and increases the risk of hypercapnia (Celli & Wedzicha, 2019). A bilaterally flattened diaphragm suggests emphysema associated with COPD (Celli & Wedzicha, 2019). Secondly, an examination of the lungs revealed bilateral wheezes, forced expiration, and prolonged exhalation phase. These features suggest the presence of obstructive pulmonary disease (Celli & Wedzicha, 2019). Thirdly, spirometry findings reveal a forced expiratory volume in the first second (FEV1) of less than 80 percent of the predicted value (64 percent), a lower forced vital capacity (FVC), and an FEV1: FVC ratio of less than 0.7 (0.56). Additionally, there are insignificant changes in the spirometry readings of the FEV1/FVC ratio after administering a bronchodilator. These findings are suggestive of chronic pulmonary disease.

Management of the Disease

1. Classify the patient’s disease severity. Is this considered stable or unstable?

According to GOLD’s criteria, the patient has moderate COPD. Based on these criteria, moderate COPD presents with an FEV1 reading ranging from less than or equal to 50 percent to less than 80 percent of the predicted value (GOLD, 2022). In this context, the patient’s post-bronchodilator FEV1 reading is 66 percent of the predicted value. The patient’s COPD is considered stable. This is because the patient’s symptoms are not severe, and a rapid pulmonary decline is absent. However, the patient should be managed adequately to avert his condition worsening.

2. Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.

Bronchodilators and glucocorticoids are examples of recommended cases of medication used in the management of COPD. Bronchodilators are short-acting and long-acting (Celli & Wedzicha, 2019). Examples of bronchodilators include albuterol, salmeterol, and ipratropium bromide (Celli & Wedzicha, 2019). Both inhaled and oral corticosteroids can be used. They include fluticasone, budesonide, and prednisolone (GOLD, 2022).

3. Describe the mechanism of action for each of the medication classes identified above.

According to Stockley et al. (2019), bronchodilators such as beta-2 receptor agonists (salmeterol) stimulate beta receptors on bronchial smooth muscles to elicit relaxation and avert constriction and spasms. Bronchodilators such as anticholinergic agents (ipratropium bromide) inhibit acetylcholine and block vagally mediated reflexes, inhibiting the influx of calcium ions on bronchial smooth muscles, hence dilation (Celli & Wedzicha, 2019).

Celli and Wedzicha (2019) report that corticosteroids inhibit the migration of polymorphonuclear leukocytes and other inflammatory mediators, control protein synthesis, and reverse capillary permeability. As such, corticosteroids prevent inflammation.

4. Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.

Non-pharmacological approaches include pulmonary rehabilitation and oxygen therapy. An interdisciplinary team accomplishes pulmonary rehabilitation. These programs address the patient holistically and can last six to eight weeks (GOLD, 2022). It entails dietary changes, smoking cessation, and physical activity (GOLD, 2022). On the other hand, oxygen therapy reduces the incidence of hypoxia and hypercapnia associated with COPD (GOLD, 2022). As such, the prognosis of the disease improves.

References

Celli, B. R., & Wedzicha, J. A. (2019). Update on Clinical Aspects of Chronic Obstructive Pulmonary Disease. New England Journal of Medicine, 381(13), 1257–1266. https://doi.org/10.1056/nejmra1900500

Global Initiative for Chronic Obstructive Lung Disease. (2022). Global Strategy for Prevention, Diagnosis and Management of Copd: 2022 Report. file:///C:/Users/NOTEBOOK%20348/Downloads/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf

Stockley, R. A., Halpin, D. M. G., Celli, B. R., & Singh, D. (2019). Chronic obstructive pulmonary disease biomarkers and their interpretation. American Journal of Respiratory and Critical Care Medicine, 199(10), 1195–1204. https://doi.org/10.1164/rccm.201810-1860SO

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We are utilizing the Week 3 Case Study TemplateLinks to an external site. Provide your responses to the case study questions listed below.
You must use at least one scholarly reference to provide pathophysiology statements. For this class, the use of the textbook for pathophysiology statements is acceptable. You may also use an appropriate evidence-based journal.

You must use the current Clinical Practice Guideline (CPG) for managing and preventing COPD (GOLD Criteria) to answer the classification of severity and treatment recommendation questions. The most current guideline may be 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.
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 by complaints of fatigue and increasing dyspnea for three months, for which he did not seek care. Cardiology evaluated him, and underwent a successful and uneventful angioplasty before 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. Before today, his last visit with your practice was three 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, 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%
Wt. 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 were 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
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

Are the spirometry results consistent with obstructive or restrictive pulmonary disease? What is the most likely pulmonary diagnosis for this patient?
Explain the pathophysiology associated with the chosen pulmonary disease.
Identify at least three subjective findings from the case that support the chosen diagnosis.
Identify at least three objective findings from the case that support the chosen diagnosis.
Management of the Disease

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

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