question archive Janis, a 59-year-old female, presents with tachypnea, dyspnea, on exertion, and mild chest discomfort
Janis, a 59-year-old female, presents with tachypnea, dyspnea, on exertion, and mild chest discomfort
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Janis, a 59-year-old female, presents with tachypnea, dyspnea, on exertion, and mild chest discomfort. She was diagnosed with emphysema 4 years ago and was placed on a bronchodilator therapy. She has an 80 pack year history of smoking. "I feel short of breath when I walk, and my chest is sore." She describes her chest soreness as mild pressure, rated 2 on a 1-10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing hard. She states she has had a nonproductive cough for 4 days and feels more fatigued than usual.
Subjective
Past medical history: she has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had 2 exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully.
Family history: Noncontributory
Social history: She lives with her husband who also smokes 2 packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.
Medications: Albuterol MDI, 90 mcg/inhalation, 2 puffs as needed every 4-6 hours; ipratropium bromide MDI, 18 mcg/inhalation, 2 puffs 4 times/day; ibuprofen as needed for arthritic pain.
Allergies: Janis is allergic to Keflex and penicillin
Objective: Janis is dyspneic at rest, sitting. Use of accessory muscles evident. Pursed lip breathing noted.
Vital signs: B/P 122/64; P: 92; R: 26; T: 102; SpO2: 88. AP to transverse ratio is 1:1
Skin: warm and dry
HEENT: Negative
Cardiovascular: RRR; S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2+/4+
Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on right and left anterior and lateral thorax from 2nd to 5th intercostal spaces. PFT conducted 2 months ago prior to visit showed obstructive flow patterns and reduced FEV1/FVC.
Abdomen: soft, with bowel sounds; tympanic to percussion
Neurologic: Negative
Critical Thinking!
Which diagnostic or imaging studies would be considered to assist with or confirm the diagnosis?
What is the most likely differential diagnosis and why?
What is your plan of treatment?
What is your plan for follow-up care?
Are there any referrals?
What additional risk factors are evident for this patient?
Are there any standardized guidelines that you should use to treat this patient?
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Which diagnostic or imaging studies would be considered to assist with or confirm the diagnosis?
Chest X-Ray can be use as a confirmatory test of her emphysema. Chest X-Ray may not be accurate during the early stage of emphysema. But since she was diagnose over 4 years ago, it will probably show up on her Chest X-Ray result. Her lungs will appear larger than it normally is.
What is the most likely differential diagnosis and why?
The signs of emphysema can be often confused with other condition since things such as shortness of breath or breathing difficulties may be misinterpreted as part of the aging process or as a result of lifestyle options. My differential diagnosis would be Pneumothorax, because pneumothorax like emphysema may appear to cause shortness of breath, dyspnea, tachypnea, and chest pain. She stated that she also has a nonproductive cough which can be caused by pneumothorax. Also, according to her medical history she undergone a medical surgery which has a high probability to cause pneumothorax.
What is your plan of treatment?
Continue her bronchodilator therapy to relieve her cough and also to open her airways to alleviate her shortness of breath. Give her antibiotics in case her emphysema may exacerbate. Corticosteroids may also be use in form of inhalation to reduce the inflammation and make breathing easier.
What is your plan for follow-up care?
For her follow up care, I want her to continue her medication. Then advise her for pulmonary rehabilitation, this will allow her to be more active. Have a backup oxygen tank at home. Have the respiratory therapist help her on breathing exercise. Advise her companion to stop smoking around her because her condition might worsen. Visit the hospital as per physicians order.
Are there any referrals?
Yes, schedule her visit to her pulmonologist to assess her progress on her medication. If there are any changes in her therapy based on the judgment of the pulmonologist for in her condition.
What additional risk factors are evident for this patient?
The additional risk factor would be the secondhand smoke coming from her husband that lives with her.
Are there any standardized guidelines that you should use to treat this patient?
Yes, the 2020 Guidelines for the Global Initiative for Chronic Obstructive Lung Disease will be a very great help because it is a step by step treatment for COPD or also emphysema. This will be a complete guide for diagnosing, managing and preventing COPD.
