NR 603 Week 2: Case Discussion: Pulmonary Part One

Setting: A free medical clinic that provides health care for the under-insured.

Your next patient, Michelle G., age 40, is a regular of the clinic and the last patient of the day. The chart states she is here for recent episodes of shortness of breath.

You enter the room and Michelle G is dressed in work clothes, standing up looking at a health poster on the wall. You introduce yourself and ask her what brings her to the clinic today. “I think I may have a cold. I’ve been having a hard time breathing on and off lately NR 603 Week 2: Case Discussion: Pulmonary Part One.”

HPI: “I notice I’m short of breath mostly at work but by the time I get home feel fine. No episodes of shortness of breath on the weekends that I can recall. But a few hours back at work and I start to feel like I cannot catch my breath again. A few months ago this happened and it was so bad I left work and went to urgent care where they gave me a breathing treatment of some kind and sent me home on an antibiotic. I would like you to give me another antibiotic. She denies sputum. No new allergy triggers noted. She denies heartburn.

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PMHx: Michelle G. reports her overall health as good.

Childhood/previous illnesses: eczema as a child

Chronic illnesses: Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist ten years ago, Took allergy shots for five years with great results, now only takes Zyrtec when needed.

Surgeries: Tonsillectomy, Cholecystectomy

Hospitalizations: childbirth x 3.

Immunizations: up-to-date on all vaccinations.

Allergies: Strawberries-Rash; erythromycin- severe GI upset.

Blood transfusions: none

Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20’s. Denies illicit drug use.

Sleeps 6 to 7 hours a night. Exercises four to five days per week.

Current medications: Multivitamin, Zyrtec NR 603 Week 2: Case Discussion: Pulmonary Part One

Social History: Married, lives with husband and 3 children. Worked in advertising up until 18 months ago when she got laid off. In order to help with the household finances she took a job as a Baker’s assistant at an Artisan Bread Bakery. She arrives at 4 a.m. every morning to begin baking breads/pastries for the day.

Family History: Children are healthy- daughter currently has a sinus infection. Parents are deceased. Mother at age 80 from congestive heart failure. Father died at age 82 from lung cancer, diagnosed when metastasized to brain. PGM: died from unknown causes, PGF: Stroke at age 82. MGM: died at 83, had HTN, atherosclerosis and many heart attacks. PGF: died at 71 from complications of COPD.

PE: Height 5’10”, Weight 140 pounds

Vital signs : BP 130/70, T 98.0, P 75, R 18 Sao2 98% on RA

General: 40-year-old Caucasian female appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless. Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.

Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.

Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender

Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses non-tender to palpation.

Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.

Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight wheezing noted inspiration and on forced expiration. Wheezing does not clear with forced cough.

CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.

Diagnostic Testing: NR 603 Week 2: Case Discussion: Pulmonary Part One

Review of the patient’s EMR reveals an old CXR from last winter when she had Bronchitis.

CXR Report: 11/7/2016

This is a PA and lateral chest radiograph on Ms. Michelle X, performed on 11/7/16. Clinical information: low grade fever, productive cough, malaise.

Findings: Cardio-mediastinal silhouette is normal. B/L lung fields are clear. There are no effusions. The bony thorax appears normal. No opacities or fluid. Diaphragm normal.

Impression: Normal chest radiograph without pathology.

You suspect an obstructive/restrictive process and order Pulmonary Function Testing

Pre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreased

Post Bronchodilator Challenge- FEV1/FVC 75%

Discussion Questions Part One:

What is your primary diagnosis for Michelle given the pattern of occurrence of symptoms, exam results, and recent history? Include the rationale and a reference for your diagnoses.
What is your first-line treatment plan for Michelle including medications, labs, education, referrals, and follow-up? Identify the drug class of each medication you prescribe and exactly what symptom it is targeted to address.
Address Michelle’s request for an antibiotic NR 603 Week 2: Case Discussion: Pulmonary Part One.

NR 603 Week 2: Case Discussion: Pulmonary Part One – SOAP Week 2

Patient Information:

M.G., 40-year-old female, race unknown, insurance unknown.

(S) Subjective:

CC: “I think I may have a cold. I’ve been having a hard time breathing on and off lately.”

HPI:

“I notice I’m short of breath mostly at work but by the time I get home feel fine. No episodes of shortness of breath on the weekends that I can recall. But a few hours back at work and I start to feel like I cannot catch my breath again. A few months ago, this happened and it was so bad I left work and went to urgent care where they gave me a breathing treatment of some kind and sent me home on an antibiotic. I would like you to give me another antibiotic. She denies sputum. No new allergy triggers noted. She denies heartburn.

Current Medications:

Multivitamin

Zyrtec

Allergies: Strawberries-Rash; erythromycin- severe GI upset.

PMHx: Michelle G. reports her overall health as good. Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist ten years ago, took allergy shots for five years with great results, now only takes Zyrtec when needed.

PSHx: Tonsillectomy, Cholecystectomy

Childhood Illnesses: eczema as a child

Immunization Hx: up-to-date on all vaccinations.

Other Screenings: Not reported.

Soc Hx: Married, lives with husband and 3 children. Worked in advertising up until 18 months ago when she got laid off. In order to help with the household finances, she took a job as a Baker’s assistant at an Artisan Bread Bakery. She arrives at 4 a.m. every morning to begin baking breads/pastries for the day.

Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20’s. Denies illicit drug use.

Sleeps 6 to 7 hours a night. Exercises four to five days per week.

Fam Hx: Children are healthy- daughter currently has a sinus infection. Parents are deceased. Mother at age 80 from congestive heart failure. Father died at age 82 from lung cancer, diagnosed when metastasized to brain. PGM: died from unknown causes, PGF: Stroke at age 82. MGM: died at 83, had HTN, atherosclerosis and many heart attacks. PGF: died at 71 from complications of COPD NR 603 Week 2: Case Discussion: Pulmonary Part One.

ROS:

CONSTITUTIONAL: No reports of fever, chills, weight loss. Report sick contact-daughter has sinus infection.

HEENT: None reported.

SKIN: None reported.

CARDIOVASCULAR: None reported.

RESPIRATORY: Shortness of breath at work. Denies sputum.

GASTROINTESTINAL: Denies heartburn.

GENITOURINARY: None reported.

NEUROLOGICAL: None reported.

MUSCULOSKELETAL: None reported.

HEMATOLOGIC/LYMPHATICS: None reported.

PSYCHIATRIC: None reported.

ENDOCRINOLOGIC: None reported.

ALLERGIES: Strawberries and erythromycin. Reports seasonal allergies-spring is worst.

Vital signs: B/P 130/70, T 98.0, HR 75, RR 18 Sao2 98% RA.

Height 5’10”, weight 140 pounds

BMI: 20.1

PHYSICAL EXAM

GENERAL: 40-year-old Caucasian female appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless.

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses non-tender to palpation. Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.

LUNGS: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight wheezing noted inspiration and on forced expiration. Wheezing does not clear with forced cough.

HEART: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema.

ABDOMEN: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted NR 603 Week 2: Case Discussion: Pulmonary Part One.

SKIN: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.

NR 603 Week 2: Case Discussion: Pulmonary Part One

Criterion	ExceptionalOutstanding or highest level of performance	ExceedsVery good or high level of performance	MeetsSatisfactory level of performance	NeedsImprovementPoor or failing level of performance	DevelopingUnsatisfactory level of performance

Application of Course Knowledge	15 Points	13 Points	12 Points	6 Points	0 Points
Application of Course Knowledge	Post contributes unique perspectives/insights applicable to the results from the physical exam and diagnosis (es). Initial post includes the most likely diagnosis/specific treatment plan given case study information with rationale and answers all questions presented in the case. Demonstrates course knowledge/assigned readings by: linking tests/interventions to diagnoses, linking diseases by identifying symptoms and patient information.	Post contributes unique perspectives or insights, but may lack some applicability to presented case study patients.Initial post includes a clinically relevant, but not the most likely diagnosis/ specific treatment plan with rationale AND/ORanswers most of the questions presented in the case. One to two (1-2) elements of specificity identified in course expectations not met.	Post has limited perspective, insights and/or applicability to presented case study patients.Initial post reflects only general knowledge of assigned readings and course content in relation to diagnosis chosen ORtreatment plan not specific to patient situation. Some evidence-based rationale may be missing. AND/ORDoes not answer questions presented in the case. Two (2) or more elements of specificity from course expectations not met.	Post perspectives are not consistent with current practice. Does not represent a logical link between assigned reading, case study info and chosen diagnosis/treatment plan.	Post offers no insight or application to the case study presentation.
Support from Evidence-Based Practice (EBP)	15 Points	13 Points	12 Points	6 Points	0 Points
Support from Evidence-Based Practice (EBP)	Initial discussion posts are supported by evidence from appropriate sources published within the last 5 years. In-text citations and full references are provided.	Initial discussion posts are partially supported by evidence from appropriate sources published within the last 5 years.In-text citations and full references are provided. Evidence-based reference(s) used but may not fully support the treatment plan.	Initial discussion posts are partially supported by evidence.Sources may not be scholarly in nature or may be older than 5 years. In-text citations and/or full references may be incomplete or missing.	Citations to non-scholarly websites given as rationale to support differential diagnoses and/or treatment plan.	Discussion posts contain no evidence-based practice reference or citation. *Students should note that factitious sources, sources that are clearly not read by the student and used, or sources that have incorrect dates will result in an automatic ZERO (0) for this section for the week.
Interactive Dialogue	15 Points	13 Points	12 Points	6 Points	0 Points
Interactive Dialogue	Presents case study findings and responds substantively to at least one topic-related post of a peer including evidence from appropriate sources, and all direct faculty questions posted throughout the week.A substantive post adds content or insights to the discussion and is supported by references and citations as appropriate.	Presents case study findings and responds substantively to at least one topic-related post of a peer. Does include evidence from appropriate sources.Responds to some direct faculty questions posted throughout the week. A substantive post adds content or insights to the discussion and is supported by references and citations as appropriate. NR 603 Week 2: Case Discussion: Pulmonary Part One	Responds to a student peer and/orfaculty questions but the posts adds limited content or insights to the discussion.Does include evidence from appropriate sources.	Responds to a student peer and/or faculty, but the nature of the response is not substantial. Does not include evidence from any resources.	Does not respond to a topic-related peer post and/or does not respond to faculty questions by Sunday.
Organization	10 Points	9 Points	8 Points	4 Points	0 Points
Organization	Discussion post presents case study findings in a logical, meaningful, and understandable sequence.	Discussion posts and are relevant to the topic but may be unclear or difficult to follow in places.	Discussion post not fully relevant to the topic. May be unclear or difficult to follow in places.	Discussion post presents case findings and plan or intervention that are sometimes unclear to follow and may not always be relevant to topic.	Discussion post is not relevant to case study.
Grammar, Syntax, APA	5 points	4 points	3 points	1 point	0 points
	APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors.	Two to four errors in APA format, grammar, spelling, and syntax noted.	Five to seven errors in APA format, grammar, spelling, and syntax noted.	Eight to nine errors in APA format, grammar, spelling, and syntax noted.	Post contains ten or greater errors in APA format, grammar, spelling, and/or punctuation or repeatedly makes the same errors after faculty feedback.
Participation	0 points deducted			Points deducted for late or missing posts
Participation	Enters first post to part one before 11:59 p.m. MT on Wednesday; and enters peer response/faculty responses and written summation before Sunday 11:59 p.m. MT. NR 603 Week 2: Case Discussion: Pulmonary Part One			10% if submitted after Wednesday 11:59 p.m. MT and before the cut-off of Sunday 11:59 p.m. MT. Students will not receive credit for work in the threads submitted after Sunday 11:59 p.m. MT.