Course
NR 507 Advanced Pathophysiology
Instructions
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 with complaints of fatigue and increasing dyspnea for 3 months, for which he did not seek care. He was evaluated by cardiology and underwent a successful and uneventful angioplasty prior to 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. Prior to today, his last visit with your practice was 3 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, who 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
- Ears: Tympanic membranes
- Nose: Bilateral nasal turbinates without redness or swelling. Nares
- Mouth: Oropharynx No mouth lesions. Dentures well-fitting. Oral mucous membranes dry.
Neck/Lymph Nodes
- Neck supple without
- No lymphadenopathy, masses or carotid bruits.
Lungs
- Bilateral breath sounds clear throughout lung fields. + Bilaterally wheezes 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 Nail beds pink without clubbing.
Chest X-Ray
- Lungs are hyper-inflated bilaterally with a flattened No effusions or infiltrates.
Spirometry ……
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 which support the chosen diagnosis.
- Identify at least three objective findings from the case which support the chosen diagnosis.
Management of the Disease
*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.
- Classify the patient’s disease 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……..
SOLUTION
- Are the spirometry results consistent with obstructive or restrictive pulmonary disease? What is the most likely pulmonary diagnosis for this patient
The spirometry results are consistent with findings for obstructive pulmonary disease. Spirometry is a physiological assessment used to measure the maximal volume of air a person can inspire and expire using maximum personal effort (Graham et al., 2019).
Specific values from the spirometry test are looked at to determine if the respiratory disease is obstructive or restrictive. These values include the FEV1 (force expiratory volume in one second) which is used to determine severity, the FVC (forced vital capacity) which is the maximum volume of air that can be expired after maximal inspiratory effort, and the FEV1/FVC ratio which is found to be decreased in obstructive pulmonary diseases and is often considered to be the hallmark sign in regard to spirometry (Langan & Goodbred, 2020). The patient in the case study, A.C., has an FEV1 of 64% pre-bronchodilator, which is well below the normal range of >80% and can be placed in the moderate obstructive disease category which has a range of 60-69% (Langan & Goodbred, 2020). The FVC value for this case study patient is 93% pre- bronchodilator. This gives us an FEV1/FVC ratio of 69% or 0.69. The GOLD criteria use a cutoff of <0.7 to establish a diagnosis of obstructive pattern pulmonary disease (Gold, 2021) and this patient meets that criterion. During a spirometry test, a bronchodilator is administered to determine responsiveness and degree of improvement of airflow as measured in changes in FEV1 and FVC (Graham et al., 2019). The values of this case study patient’s FEV1 increased to 66 and the FVC increased to 102. This actually decreased the FEV1/FVC ratio to 64% or 0.64. Obstructive defects can be characterized by their degree of reversibility (meaning improvement) following bronchodilator administration using a short-acting bronchodilator and full reversibility is typically seen in cases of asthma but is absent or incomplete in cases of chronic obstructive pulmonary disease (Langan & Goodbred, 2020). The most likely diagnosis for this patient is COPD or chronic obstructive pulmonary disease.
- Explain the pathophysiology associated with the chosen pulmonary
Chronic obstructive pulmonary disease (COPD) is a disease characterized by limitations in airflow that is not fully reversible, typically progressive in nature, and includes two types that may overlap in symptoms, chronic bronchitis and emphysema….please click the purchase button below to access the entire solution at $15