NURS 5002 Case Study #4 Megan Schleigh

Refer to Case Study Grading Guidelines and Grading Rubric for a complete description of requirements and grading criteria. To make
the case study as real as possible, while you are working through the case study do not look ahead at the information provided.

You are working in a Family Practice office and Cheryl, a 42 yo female with c/o wheezing and SOB is the next
patient. Her chart reveals the following:

PMH SH MEDS
Acute bronchitis X2 ½-1 ppd smoker Alesse
UTI Social alcohol
Obesity 2-3 cups coffee/day PRN:
2-3 diet soda/day Acetaminophen
Lives with boyfriend Ibuprofen
Works full-time Famotidine

FH
Mother – HTN, GERD NKDA
Father – HTN, asthma, DM

As you prepare for this visit what are your primary concerns? Upper Respiratory Infection, Asthma, COPD

Based on the medications listed, what are your concerns? PE

Upon Assessment of the patient you find the following information:

Cheryl is having trouble breathing with some wheezing since she has started walking this Spring to lose weight. She has been walking
outside and started with about 10-15 minutes three times per week. When she started increasing her time walking she noticed it
was getting harder to breathe and at times she would wheeze. She initially thought it was due to the warmer weather and her just
being overweight. She has never really exercised and has a job that limits activity and is mostly at a desk.

ROS
- orthopnea, chest pain, dizziness, indigestion, diarrhea, N/V, recent weight change, HA, sore throat,
+ occasional cough more prominent while walking, productive at times with clear sputum, some ankle edema after walking,

Physical Exam
Patient is alert and oriented in NAD
EENT – PEERLA, posterior pharynx slightly red with postnasal discharge, nasal mucosa pink; no adenopathy appreciated; TMs without bulging or
retractions bilaterally
Heart RRR without murmur, rubs or clicks; no carotid bruits auscultated; pedal pulses 1+, radial pulses 2+, ankles large with small amount of
edema (non-pitting)
Lungs sounds coarse but CTA bilat anterior and posterior
Abdomen large, round, soft, non-tender; bowel sounds present x4 quads; no masses palpable; unable to palpate liver border;

VS
BP 132/84 P 86 RR 20 O2 Sat 98%
Ht. 5’4” Wt. 195 lbs

What other question(s) would you like to ask Cheryl to assist with your diagnosis? What other information would you like to have
had? How long has she been smoking? Has she ever had heart problems? Does she have kidney problems? Does she have lung
problems? Ideally, I would like to look at a chest xray. I would like to have a chem 7 to look at kidney function. I would also like to
know her BNP. If BNP was elevated, I would like an echocardiogram.

DIFFERENTIATION OF DISEASE

Add 4th potential disease based on symptoms. (may add other columns if needed)

DISEASE #1 DISEASE #2 DISEASE #3 DISEASE #4

 CHF Asthma Bronchitis COPD
Reference: Patho book Reference: Patho book Reference: Patho book Reference: Patho
book
Pathophysiology Inability of the heart to Airway epithelial Acute infection or Airflow limitation that
generate an adequate exposure to antigen inflammation of the is not fully reversible
cardiac output to perfuse initiates both an innate large airways, or and is usually
vital tissues. and adaptive immune bronchi. progressive.
response. Many cells and
Contractility is reduced cellular elements 90% of cases of acute Changes occur in the
by diseases that disrupt contribute to the bronchitis are caused by large central airways,
myocyte activity. persistent inflammation of viruses. small peripheral
the bronchial mucosa and airways, and the lung
These diseases hyperresponsiveness of pg 1185 parenchyma. Chronic
contribute to the airways, including irritant exposure
inflammatory, immune, dendritic cells, T helper 2 recruits neutrophils,
and neurohumoral lymphocytes, B macrophages, and
changes that disrupt lymphocytes, mast cells, lymphocytes to the
normal myocardial neutrophils, eosinophils, lung, resulting in
extracellular structure. and basophils. progressive damage
Stroke volume falls, left from inflammation,
ventricular end diastolic pg. 1178 oxidative stress,
volume increases, heart extracellular matrix
dilates and increases in proteolysis, and
preload apoptotic and
autophagic cell death.
pg. 1098
pg 1181
Signs/Symptoms Pulmonary vascular Pts are asymptomatic Cough, fever, chills, Dyspnea on exertion,
congestion, inadequate between attacks. At the malaise, chest pain, marked dyspnea even
perfusion of systemic beginning of an attack, at rest, productive
circulation. Dyspnea, the individual experiences Usually a non- cough, thin
orthopnea, cough with chest constriction, productive cough that is appearance, accessory
frothy sputum, fatigue, expiratory wheezing, aggravated by cold, dry, muscles for breathing,
 decreased urinary dyspnea, nonproductive or dusty air that occurs barrel chest,
output, and edema. coughing, prolonged in paroxysms. hyperrsonant
expiration, tachycardia percussion.
pg 1101 and tachypnea. Severe pg. 1185
attacks involve use of pg. 1184
accessory muscles, and
wheezing is heard on both
inspiration and expiration.

pg. 1179
Treatments: Oxygen, nitrates, Avoid triggers, inhalers, Usually self- limited Prevention of COPD
morphine, diuretics, breathing treatments, is the best treatment.
inotropic drugs, ace bronchodilators, oxygen, Antitussives, beta2
inhibitors, beta blockers, immunotherapy, agonists if wheezing Treatment is based on
PCI, bypass, IABP, corticosteroids, and symptom management
LVADs mechanical ventilation if pg. 1185-1186 as it is not reversible.
needed. Bronchodilators,
pg 1101 expectorants,
pg. 1181 mucolytics,
corticosteroids,
antibiotics if there is
an infectious process,
CPT, breathing
exercises, oxygen if
needed with caution

Pg. 1185
Complications: Respiratory failure, Hypoxemia, respiratory Pneumonia, chronic Respiratory failure,
dysrhythmias, ischemia alkalosis/acidosis, bronchitis (COPD), infection, weight loss,
respiratory failure, death respiratory failure muscle weakness,
pg. 1101 increased
pg. 1179-1181 (vitalhealthzone.com) susceptibility to
comorbidities, and
 death

pg 1184
What is your choice of
disease for the given ☐ ☐ ☒ ☐
scenario? (place X in
the box)

What is the detailed rationale for the 4th potential disease that you chose? Tobacco smoke (cigarette, pipe, cigar, and environmental
tobacco smoke) is a major risk factor for developing COPD (pg. 1181)

Why did you make your choice of disease/diagnosis? Give good rational for your decision. Since the ankle swelling only occurs after
walking I am leaning away from heart failure. COPD is a concern for me, but at this time I am going to say that she has bronchitis to
see if it self resolves or until further testing is needed. Bronchitis would cause short of breath, paroxysmal coughing, and might
produce sputum and wheezing.

COMPARISON OF MEDICATIONS
Add 3rd and 4th potential medications. (may add other columns if needed)

MEDICATION #1 MEDICATION #2 MEDICATION #3 MEDICATION #4

Proventil HCA Aerospan Tessalon Pearles Guaifenesin
(albuterol)
Reference: Reference: Reference:
Reference: Rxlist.com Rxlist.com Rxlist.com
Rxlist.com
Class/Type of med Bronchodilator Corticosteroid Non-narcotic oral Exporant
antitussive
Mechanism of Relatively selective Decreases inflammation in Anesthetic numbing Stimulating receptors
Action beta2-adgrenergic lungs action on the lungs in the gastric mucosa
bronchodilator that initiate a reflex
secretion of
respiratory tract fluid,
 thereby increasing
the volume and
decreasing the
viscosity of bronchial
secretions
Indications Indicated in adults and Maintenance treatment of Symptomatic cough Helps loosen phlegm
children 4 years of age asthma as prophylactic relief (mucus) and thin
and older for the therapy in adult and bronchial secretions
treatment or prevention pediatric patients 6 years of to rid the bronchial
of bronchospasm with age and older. passageways of
reversible obstructive bothersome mucus,
airway disease and for the NOT used for acute asthma drain bronchial tubes
prevention of exercise- attack and make coughs
induced bronchospasm. more productive.
Helps loosen phlegm
and thin bronchial
secretions in patients
with stable chronic
bronchitis.

Side Effects Tremor, tachycardia, Headache, vomiting, Sedation, headache, Nausea, vomiting,
nervousness, palpitations, dyspepsia, increased cough dizziness, confusion, dizziness, headache,
dizziness, headache constipation, nausea, rash, urticaria,
upset stomach, pruritis,
nasal congestion,
burning eyes,
Complications Allergic reaction, back Infection, Bronchospasm, Kidney stone
pain, fever, chest pain, pharyngitis/rhinitis/sinusitis, laryngeal spasm, death formation, overdose
urticaria, angioedema, epistaxis, from overdose, visual
rash, bronchospasm, and immunosuppression, hallucinations,
oropharyngeal edema hyperglycemia, hyper- cardiovascular collapse
corticism, adrenal
 suppression, reduction in
bone mineral density,
effects on growth,
glaucoma, increased
intraocular pressure,
cataracts, bronchospasm
What is your choice
of trmt. for the given ☒ ☐ ☐ ☒
scenario?
(place X in box)

Why did you make this choice for treatment? Give good rational for your decision I think that this is bronchitis unless symptoms do
not self-resolve. Albuterol (Proventil) will help dilate the bronchioles and help with wheezing. Guaifenesin is an expectorant and will
help get up secretions.

What are other potential choices you could make for treatment? Pulmonary excises (vol-dine, flutter valve), natural drink remedies such as
a mixture of apple-cider vinegar, honey, and water to help with symptoms of bronchitis.

What education will you provide your patient based on her treatment, diagnosis and disease prevention? How to use her new medications. Tell
her that bronchitis should be self-limiting, and symptoms should start to improve soon. If symptoms do not get better or get worse, to
come back within two weeks for further testing/treatment options.