Lucelia Borges Discuss the Mr

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Lucelia Borges

Discuss the Mr. Barley’s history that would be pertinent to his respiratory problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.

Mr. Barley is a 58 year old male who has visited the hospital with chief complaint of productive cough with white phlegm and dyspnea upon exertion. His history of present illness reveals that he is suffering from productive cough and dyspnea since past two weeks. His past medical history reveals that he has had these symptoms since the last two winters. He does not have a medical history of cardiac or pulmonary insufficiency. He had tonsillectomy when he was 12 years old and did not have any respiratory complications in the past. He is not suffering from any chronic illness such as CHF, pulmonary embolism, anemia, depression or anxiety. He is a chain smoker with a 40 pack/ year history and has never quitted smoking in the past. He denies any symptoms of fever, chest pain, epigastric pain, recent travel etc. However, his smoking habit is a risk factor for bronchitis or COPD. His family history revealed a stress-free lifestyle with a wife and grown up children. He runs a farm but denies any exposure to chemicals because he does organic farming and also wear protective clothing. His social history also revealed a glass of bear per day along with smoking habit. His family health history revealed a decreased father who died with stroke at the age of 70 and a mother who have hypertension (Jensen, 2018). 

Describe the physical exam and diagnostic tools to be used for Mr. Barley. Are there any additional you would have liked to be included that were not? 

 

The vital signs reading of Mr. Barley are temperature 98.9F, heart rate 94 beats/minute, RR 22 breaths/min, and BP 128/78 mmHg. The general appearance of patient was mild shortness of breath and coughing. The HEENT exam revealed that patient is normocephalic with normal conjunctivae, PERRLA normal, oropharynx normal, and no masses on neck lymph nodes. The lungs showed an increased AP diameter and laryngeal height was 2 cm from the sternal notch to thyroid cartilage. Inspiratory crackles at the base of lung and end-expiratory wheezing sound was heard upon full expiration. The heart beat was regular and no abdominal tenderness was observed. The patient history and physical exam findings are indicative of COPD since patient has some classic signs of COPD. An increased anteroposterior diameter, wheezing, and decreased diaphragm length are indicative of COPD (Jensen, 2018). 

 

After physical exam, the pulmonary function test (PFT) for Mr. Barley was ordered. The FEV1/FVC ratio for this patient both pre and post bronchodilator administration was 69%. A FEV1/FVC ratio of less than 70% is indicative of COPD. The patient’s symptoms of dyspnea does not improve after bronchodilator administration is another indication of COPD because the damage is irreversible contrary to asthma which is reversible. However, the FEV1 value of patient is normal and the FEV1 value of >80% showed GOLD signs of mild COPD. A chest X-ray can also be taken to rule out any other differential diagnosis of dyspnea and cough in this patient. However, PFT is the most reliable test for assessing pulmonary diseases (Sato & Mishima, 2016).

What plan of care will Mr. Barley be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?

The therapy for Mild COPD is a short-acting bronchodilator like albuterol metered dose inhaler which the patient is instructed to take upon exertion. The most important patient education for Mr. Barley is to quit smoking at once. Mr. Barley was not sure if he wants to opt for a nicotine replacement therapy at this visit. However, Mr. Barley again got a COPD exacerbation and was prescribed an antibiotic for relieving symptoms of dyspnea, cough, and yellow-colored phlegm. He then agreed for smoking cessation therapy and nicotine replacement, and now smoke-free. He is also given long-acting bronchodilator tiotropium along with albuterol to prevent exacerbations. He is asked to have follow-up visits every six months and have a PFT annually (Prins et al. 2019).