59-year old male with shortness of breath - PowerPoint Presentation

Slide1

59-year old male with shortness of breath

State University of New York Polytechnic Institute

Presented by Francine BassettSlide2

Patient & Source of Encounter

T.I., 59-year old male

Elizabethtown Community Hospital – Emergency DepartmentSlide3

HPI

59- year old male patient presents to the ER via personal vehicle with c/o shortness of breath

x

3 days. Pt reports his illness began on Monday morning. By Monday evening, pt reports he lied down and it became difficult to breath, with sudden onset. He had chest pressure that lasted approximately 30 seconds that went away after he sat up and took a deep breath.

He was also clammy. Pt tried to take “cough syrup” once on Tuesday which didn’t work. He hasn’t taken any since then. Denies taking any other medications, antibiotics, or tried other interventions. Pt continues with a dry, non-productive cough, worse when laying flat and at night. Pt states he has been sleeping in the tripod position with pillows since Monday night.

Today (Thursday), the school pt works at called the ER stating he was coming in. Upon arrival to the ER, pt admits to constant, non-radiating, mid-

sternal

chest pressure, worse when lying down, improved by sitting up. Denies pain. Admits to

dyspnea

,

orthopnea

, cough, body aches. Denies chills, fever, nausea, vomiting,

abd

pain, ear pain, sore throat. Denies any recent travel/limited movement.

Daily cig Smoker = 10 pack years. Denies ETOH abuse or recreational drugs. Denies any known past medical history. Doesn’t recall last visit to a health care provider. Denies any medication history. Denies receiving flu and pneumonia vaccine. Denies sick contacts.Slide4

ROS

General: Denies fever, chills, night sweats.

Skin: Admits to sweating.

Ears: Denies ear ache.

Nose/sinus: Admits to clear nasal discharge. Denies post nasal discharge, sinus pain or infections.

Mouth/throat: Denies sore throat.

Respiratory: Admits to pain,

dyspnea

,

orthopnea

, wheezing, cough. Denies asthma, bronchitis, COPD, sputum.

Cardiac: Admits to pressure,

dyspnea

. Denies HTN, syncope, edema

Peripheral vascular: Denies blood clots.

GI: Denies nausea, vomiting,

abd

pain.Slide5

History

PMHx

Patient denies any known past medical history.

Medications:OTC

Cough syrup x1 past Tuesday – unknown name.

Hospitalizations/injuries/accidents: Denies.

Allergies: Denies allergy to food, latex, environment, or medications.

Immunizations: Denies flu and pneumonia.

Family

HxDenies any familial hx of cardiac, blood disorders, or respiratory problems.

Social

Hx

Occupational: Maintenance at grade school

Habits: 10 pack year smoker. Denies illicit drug use. Denies ETOH abuse.

Slide6

Physical Exam

General appearance: 59-year old acutely ill male, pale, in moderate respiratory distress, sitting upright on stretcher.

VS: T98.1, RR 20, P 90, BP 171/70, Spo2 92% RA (on arrival)

97%2LNC

Ht/Wt/BMI: 72in/160lb/21.7

Skin: Pale, warm, dry. Absence of rashes.

Eyes: Sclera white,

anicteric

.

Ear: EAC’s without drainage or edema. TM’s pearly gray, cone of light 5 o’clock Right, 7 o’clock left. Throat/mouth:. Posterior pharynx pink, without exudates. Uvula midline. Tonsils +1 bilaterally.

Neck: Absence of

lymphadenopathy

. Trachea midline.

Chest/lungs: Labored, deep, respirations. AP diameter 1:2. Coarse crackles bases bilaterally. Upper lobes with expiratory wheezes. Using accessory muscles,

supraclavicular

retractions. Mid-

sternal

pressure. Resonant to percussion.

CV/PV: RRR. S1:S2. No murmurs,

gallos

, rubs, clicks, heaves, thrills. Absence of carotid bruits. Cap refill <2seconds. Strong 2+ radial and pedal pulses bilaterally. Absence of peripheral edema.

Abdomen: Flat. Absence of

hepatosplenomegaly

.

Neurological: Alert and oriented to self, place and time. Speech intact. Slide7

Differential Diagnosis (so far)

DVT

Pulmonary Embolism

MI

CHF

Pneumonia

Bronchitis

COPD/asthma exacerbationSlide8

Diagnostics/Work-up

CXR

EKG

CBC

CMP

D-

Dimer

Troponin

BNPSlide9

Treatment

Saline lock

2LNC Oxygen

Duoneb

(

Albuterol/Ipratropium

) INH x1

Short acting bronchodilator/short acting

anticholinergicSlide10

Post-treatment

Oxygen: Spo2 92%

97% 2LNC95% RA at discharge

After

Duoneb



Wheezes

improved

upper lobea. Coarse crackles absent. Clear bases bilaterally.VS: BP 148/76, HR 87, Spo2 99% 2LNC,

rr

18Slide11

Diagnostics - Results

CXR



No infiltrates or consolidation.

Nml

.

EKG



Sinus rhythm

CBC



WNL

CMP

WNL

D-

Dimer



50 (<=250)

Troponin



<0.02

BNP

 586 (<200)Slide12

Diagnosis – Rule out

DVT

Pulmonary Embolism

MI

CHF

Pneumonia

Bronchitis

COPD/asthma exacerbationSlide13

Diagnosis

Obstructive chronic bronchitis with Exacerbation ICD-9 491.21Slide14

Etiology

Prolonged exposure to bronchial irritants

Smoking, environmental, occupational

Chronic, poorly controlled respiratory allergies

Chronic respiratory infections

Low birth weight

(

Hollier

& Hensley, 2011, p. 576)(Global Initiative for Chronic Obstructive Lung Disease, 2015,p. 6) Slide15

Incidence

14.2 million people – COPD

12.5 million people – Chronic bronchitis

Fourth leading cause of death in United States

(

Hollier

& Hensley, 2011,

p

. 576) Slide16

Pathophysiology

Inflammatory disease of the mucus membranes of the bronchi

Increased amount of sputum throughout part or the entire year.

Chronic irritation leads to increase in mucus production

Mucus gland hyperplasia and increased risk for infection

Airway narrowing and increased airway resistance, fibrosis around bronchioles

All these factors result in airway narrowing = obstructive disease

(Higginson, 2010, p.107-108)Slide17

Management Plan

Ventolin

MDI (

Albuterol

sulfate) 90mcg 2 puffs INH Q4-6H PRN

Short acting bronchodilator

Prednisone taper (corticosteroid)

Z-

pak

Zithromax (Azithromycin) 250mg PO daily x6days Macrolide AbxSlide18

Education

Minimize exposure to irritants

Pneumococcal & influenza vaccine

Reduce exposure to persons with respiratory infection

Increase fluid intake

Pursed lip breathing (if needed)

Smoking cessationSlide19

Follow-up

Every 3-6 months for stable disease

Maintain close follow-up with patients with acute respiratory infections

Review treatment plan with patient at each visit

(

Hollier

&

Hensely

, 2011,p. 576)Slide20

References

Global Initiative for Chronic Obstructive Lung Disease. (2015).

Pocket guide to COPD diagnosis, management, and prevention

. Retrieved February 18, 2015 from

http://www.goldcopd.org/uploads/users/files/GOLD_Pocket_2015.

pdf

Higginson, R. (2010). COPD:

pathophysiology

and treatment.

Nurse Prescribing, 8(3), 102-110. Hollier, A., &

Hensley,R

. (2011).

Clinical guidelines in primary care: A reference and review book

.

Lafayette,LA

: Advanced Practice Education Associates.