Adult Health II Case Study - Diane Morris - Home



Adult Health II Case StudyDiane MorrisWASHBURN UNIVERSITYAdult Health II Case StudyCHIEF COMPLAINT: “I finished the antibiotic you prescribed last week for my bronchitis but my cough is getting worse and I am still short of breath”. HISTORY OF PRESENT ILLNESS: This pleasant 59 year old white male presents to the clinic today for continued coughing and increasing shortness of breath since his visit 7 days prior for fever and cough. He was seen 7 days ago by Angela Rupp, APRN and diagnosed with acute bronchitis with COPD exacerbation. The patient (pt) was treated with an oral course of Doxycycline and prednisone. Pt was also encouraged to increase Albuterol/Atrovent use to every 6-8 hours on a scheduled regimen for several days, as well as continued use of daily Symbicort. Pt reports that he finished the antibiotic and is still taking the prednisone and using nebulized Albuterol/Atrovent every 8 hours. At times he reports having to use his rescue Albuterol MDI nearly at least once per day. He states he no longer has fever but his cough remains the same. He denies chills or myalgias at this time. He voices concerns that he has developed pneumonia, since this is the way he felt before when he had pneumonia. He reports that he has been unable to go for his usual walks in the mall due to shortness of breath and states that even at rest he occasionally feels “winded” with audible wheezing intermittently. PT AGE/GENDER/RACE: 67 year old, white malePERTINENT PAST MEDICAL/SURGICAL HISTORY: HypertensionChronic Obstructive Pulmonary DiseaseHypercholesteremiaRepaired bilateral inguinal hernias (approximately 20 years prior)Impaired Fasting GlucoseSOCIAL HISTORY: Pt smokes approximately 2 packs of cigarettes per day for past 40 + years. Pt drinks alcohol only on occasion, approximately 2-3 beers per week. Denies recreational drug use. Pt lives independently with his wife of 42 years. Pt has 2 adult living children and 2 grandchildren who all live locally. FAMILY HISTORY: Family history significant for: Mother - HTN, myocardial infarction (deceased)Father – Valvular heart disease and CAD (open heart surgery repair/CABG), still living age 90Brother – COPD (still living)SPIRITUAL CONSIDERATIONS: Pt states he is Catholic but does not attend church routinely. When asked about particular spiritual preferences, he stated “well, I think God has a plan for everyone and I am no different…I suppose I could change my smoking habits but I think what’s done is done”. CULTURAL CONSIDERATIONS: Pt is a retired farmer from Garnett, KS area. Resident of a small rural community in which he is active doing odd jobs and volunteering at community events.MEDICATION ALLERGIES:AugmentinCephalosporinsCodeineCrestorPCNsCURRENT MEDICATIONS:Abuterol/Ipratropium Inhalation SolutionHCTZ/Lisinopril MeloxicamMetforminSymbicortPrednisoneREVIEW OF SYSTEMS: Constitutional – Alert, oriented x3, skin warm and dry, able to participate in review. Had been feeling slightly ill for the past 5 days with complaints of increased coughing, fever and shortness of breath with exertion. States fevers have resolved after finishing antibiotic. Pt is minimally dyspnic with ambulation.Eyes – No changes in vision. Denies double vision, blurry vision. Pt wears glasses regularly.ENT – Reports some nasal congestion with occasional clear nasal drainage. No hearing difficulty or changes. Denies ear pain or drainage. Complains of mild “scratchy throat” for 3-4 days. Skin – No rashes or open wounds. Cardiovascular – Denies chest pain or palpitations. Pulmonary – States mild shortness of breath both at rest and increased upon exertional activities. Frequent cough with small amount clear/yellowish sputum production, especially in the morning. Pt states has had occasional wheezing and increased use of Albuterol rescue inhaler. States had 2 previous episodes of pneumonia in the past 5 years. Most recent CXR was about 2 years ago when seen by pulmonology for new diagnosis of COPD, only notable findings on previous CXR were typical increases in AP diameter due to COPD. Does not wear oxygen either during the day or at night. Endocrine – Slightly decreased appetite for approximately 1 month, no reported weight loss. Gastrointestinal – Denies nausea/vomiting/diarrhea. Reports daily bowel movements unchanged, without reports of blood in stool. Genitourinary - No increased frequency or pain with urination. Reports nocturia usually x1 per night. Musculoskeletal – Denies changes in muscle strength. Reports only mild, occasional crepitus and pain in knees bilaterally. No recent falls. Neurologic – Denies changes in either long or short-term memory. No reports of headache or dizziness. Psychological – Reports contentment in life without changes in mood.Heme/Lymph – Denies any noted swollen/tender lymph nodes. Denies increased bruising or rashes. Reports no history of deep vein thrombosis or pulmonary embolism. PHYSICAL EXAM: Vitals: Temp 37.0 (orally), HR 68, RR 20, O2 Sat 91% (room air), BP 140/78. Weight 75.9 kg. Height 138.5 cm. BMI 39.6.General: Shows a pleasant gentleman, appearing older than his stated age. Mild respiratory distress noted. Pt sitting upright in somewhat a tripod position, noted mild dyspnea with speaking for more than a few minutes. Skin color pink, warm and dry. Eyes: PERRLA, EOM intact. Sclera and conjunctiva clear without drainage. ENT: TM clear, with small amount cerumen bilaterally, no other otorrhea. Mild erythema to posterior pharynx, no exudate. Uvula midline without edema. Nasal mucosal pink with small amount clear nasal drainage noted. Lymph Nodes: No lymphadenopathy. Cardiovascular: RRR without ectopy or murmur. No carotid or abdominal bruits noted.Respiratory: Mild/moderate expiratory wheezing throughout lung fields. Noted minimal crackles to RLL. Frequent deep coughing with small amount clear sputum produced. Skin: Warm and dry skin, no rashes or ecchymosis noted. Psychiatric: No obvious distress. Appears calm with clear speech. Abdomen: Normoactive bowel sounds x4 quadrants. Soft and non-tender. No abd bruit.Genitourinary/rectal: Did not do GU or rectal exam at this visit.Extremities: No noted edema. Mild cyanosis to fingernails, no clubbing. Cap refill 2 seconds.Musculoskeletal: Strength 5/5 in all extremities. Nl ROM in all extremities. No deformities, mild crepitus noted in bilateral knees with flexion/extension. Neurologic: A/O x3. Speech clear, regular rate with voice quality strong and steady (although dyspnic with continued conversation). Conversation is smooth and easily understood with adequate comprehension and attention. Ambulated into room moving all extremities without deficits. Gait steady. Patellar reflexes intact. PERTINENT DIAGNOSTIC TESTS: (Ferri, 2012)CXR: LUL consolidation (? Pneumonia vs. nodule) Oxygen saturation: 91% on room airDIFFERENTIAL DIAGNOSIS: (Ferri, 2012)Acute COPD exacerbationAcute/Chronic BronchitisPneumoniaLung Neoplasm or other pathology such as lung abscess/benign lesionsTuberculosisCHFIMPRESSION/FINAL DX:COPD acute exacerbation (on oral steroids)Abnormal CXR (possible pneumonia vs. nodule/neoplasm)PLAN: Due to the questionable abnormality seen on the PA/Lateral CXR performed on the second clinic visit, coupled with the pt’s continued cough, dyspnea and smoking history, he was sent for a chest CT scan (this was ordered after discussion of the case with Dr. Morrison, the collaborating physician in the clinic) (Alberts, 2007).Pt was instructed to continue oral steroids (Ferri, 2012).Continue Albuterol/Atrovent nebulized treatments (Ferri, 2012).Follow-up in 3 days in clinic for re-evaluation and discussion of CT results. Instruct patient on importance of smoking cessation (National Cancer Institute, 2012).The patient presented for this office visit alone. Giving the patient the difficult news that there was something abnormal on his CXR was difficult, since the patient’s first question was “is it lung cancer?” Obviously, this was a real possibility due to the patient’s long standing history of heavy cigarette smoking. The patient’s wife did not accompany him to this appointment but the patient asked my preceptor to call her later that day to discuss the reason for the recommended CT scan, as he was confident she would have additional questions. My preceptor was more than happy to do this, since the she is well known to my preceptor as a friend and her own patient. REFLECTION AND ADDITIONAL INFORMATION:After seeing the patient on this day, he underwent the recommended CT chest scan with contrast that revealed a solid appearing mass within the left upper lobe measuring 12 mm, without evidence of lymphadenopathy or additional pulmonary nodules. Mild to moderate predominant central lobular emphysema was also noted on CT scan. The patient then underwent PET scan, which showed the mass, as well as abnormal activity within the left hilum, which correlated with a borderline enlarged left hilar node measuring 10 mm. The patient was then referred to the Heart and Lung surgeon group for evaluation and recommendation to treat the left lung mass. After this appointment and consultation with the thoracic oncology multidisciplinary clinic, it was determined that the best approach for the patient was to perform a diagnostic bronchoscopy, a left anterior Chamberlain procedure to assess hilar lymph nodes, and then a possible left thoracotomy, if lymph nodes are positive. Thoracotomy would provide a wedge resection of the left upper lobe mass (Bach, Silvestri, Hanger, & Jett, 2007). Unfortunately, the patient was found to have positive lymph node involvement. He underwent a wedge resection. Pathology determined the left upper lobe mass was an “invasive moderately to poorly differentiated adenocarcinoma”, with lower paratracheal lymph nodes revealing “metastatic adenocarcinoma”. He will now follow oncology to begin radiation and potentially chemotherapy, if the patient is willing (Ferri, 2012, p. 601). After reflecting upon this particular presentation and case, I feel that the appropriate treatment was given upon original presentation. The purpose of obtaining the original CXR was essentially to rule out pneumonia, due to the recent bronchitis infection; however, it was discovered that the patient actually had more severe pathology on xray. Accurate interpretation of this xray was crucial in making sure the patient was referred for additional imaging and consultation by pulmonary specialists. Sadly, this case of primary lung adenocarcinoma had already metastasized to local lymph nodes upon diagnosis. I believe this type of case speaks to the importance of nurse practitioner training on basic radiology interpretation. It also causes me to reflect on the controversial subject of routine CXR or CT scans for lung cancer screening purposes (National Cancer Institute, 2012). One must wonder that if this patient had an earlier screening with CXR or CT imaging, would that have resulted an earlier diagnosis before metastasis? Given the nature of adenocarcinomas in general, early metastases are common and patients’ are often asymptomatic. Due to diagnosis at later stages, adenocarcinomas can have poorer prognosis if distant metastases are present (Wikipedia, 2012).ReferencesAlberts, M. W. (2007, September). Diagnosis and management of lung cancer executive summary. CHEST, 132(3), 1s-19s.Bach, P. B., Silvestri, G. A., Hanger, M., & Jett, J. R. (2007, September). Screening for lung cancer. CHEST, 132(3), 69s-77s.Ferri, F. F. (2012). Ferri’s Clinical advisor. Philidelphia, PA: Elsevier.National Cancer Institute. (2012). Wikipedia. (2012). en.wiki/Adenocarcinoma_of_the_lung ................
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