Case Study Number One

HPI:  JS is a 74 year old man who presents to your family medicine office with his wife complaining of shortness of breath and fever. They just moved to the area and had been planning to come to your office next week to establish care as new patients. Due to the onset of symptoms, JS called and was given a walk-in slot today. His wife did bring records from his last physician’s office.  She has noted no change in his alertness or mental status. Wife states that JS usually has a cough, worse in the morning, productive of gray sputum, gets short of breath if he walks more than 10 feet, and has episodes of wheezing if he gets sick (e.g. with an upper respiratory infection). He usually is able to help around the house with light work and fixing things. Currently, the patient has been unable to speak in full sentences for the past several hours per wife. He has a productive cough with sputum of unknown color with audible wheezing since last night. He is experiencing mild chest tightness and dyspnea.

Past Medical/Surgical History

·         Heart failure following myocardial infarction at age 68 years

·         COPD (on 2 L home oxygen)

·         Hypertension

·         Appendectomy

Family History

·         Father died of myocardial infarction at age 59 years (diabetes, hypertension, smoker)

·         Mother alive (atrial fibrillation, heart failure)

·         Healthy siblings

Social History

·         Married, 3 adult children

·         30 pack year smoking history (quit after MI)

·         Worked on a farm

·         No alcohol or illicit drug use

Medications / Allergies

·         Lisinopril 20 mg twice daily

·         Metoprolol 50 mg twice daily

·         Spironolactone 25 mg daily

·         Furosemide 40 mg daily (Diuretic)

·         Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff inhaled twice daily

·         Tiotropium DPI one cap inhaled daily                

·         Albuterol/ipratropium metered dose inhaler (MDI) or solution for nebulization every 6 hours as needed

·         Levalbuterol – a beta2 agonist.  MDI two puffs every 4 to 6 hours as needed

·         Home oxygen

·         Beta blocker

He is confused about what to use when, so you are not sure which medications he actually takes. No known allergies.

JS Past Record Review (brought by wife)

·         Echocardiogram with EF of 25%

·         Spirometry with FEV1 35% predicted that does not change significantly after inhaled bronchodilator

Unable to determine when last pneumoccal vaccine was give.

Patient and wife don’t recall “a pneumonia shot”.

Does know he got his “flu shot” last month at a grocery store.

An arterial blood gas (ABG): pH 7.17, PCO2 55, PO2 62, HCO3- 25

Physical examination

Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 132 lbs; T 101.5 °F oral.
Unable to speak in full sentences, audible wheezing, alert and oriented

Pertinent positives:

General:  audible wheezing, no accessory muscle use
Nails: tar stains, clubbing
Chest: increased anteroposterior (AP) diameter; diffuse wheezing to auscultation
Heart: regular, no murmurs

In your case report, be sure to address the following questions:

1. At this point, can you think of at least two diagnoses?  What is your most likely diagnosis? 

Pneumonia with COPD exacerbation, URI with COPD exacerbation, pulmomary edema related to congestive heart failure. The most likely diagnosis is COPD exacerbation with pneumonia.

2. Explain the main reasons for your diagnosis.   

The patient is experiencing wheezing, productive cough with colored sputum, and running a fever. All of these symptoms are indicative a respiratory infection. The chest tightness and dyspnea indicate a lower respiratory infection. Because of his age, his COPD and history of CHF, this patient is at increased risk for pneumonia.

3.  How would you interpret his clinical picture?  Hint:  Use the GOLD criteria for COPD (Look this up)

Based off of this patients FEV of 35%, he is classified as having stage III, or severe COPD. FEV is a percentage of the FVC. In a normal, healthy lung, FEV is typically 72-85%. FEV is decreased in obstructive lung disease.

4. In a patient with COPD, assessment of symptoms should include the following?

·         Severity of breathlessness

·         Sputum production

·         Wheezing

·         Weight loss/anorexia

·         All of the above

All of the above should be considered.

Severity of breathlessness should be considered to determine what sort of interventions are needed to restore adequate ventilation.

Sputum production should be considered because the character of it can shed light on the pathology associated with it. For example, frothy sputum is commonly accompanied by COPD exacerbation because it may be mixed with surfactant from the lungs. Thick clear or thicky yellow tinged mucus may be associated with a viral pneumonia infection. Pink tinged mucus may be associated with asthma due to the presence of eosinophils.

Wheezing is a result of narrowing of the airways and should be considered to determine methods to reopen the airway.

Weight loss and anorexia should also be considered because patients with COPD may expend additional calories expanding and contracting the muscles involved with breathing.

 

5. Which of the following is the least likely cause of patient’s symptoms?

·         COPD exacerbation

·         Recurrent aspiration

·         Heart failure

·         Pneumonia

·         Asthma exacerbation

Asthma is the least likely cause of the patient’s symptoms. Lung infection is the most common cause of COPD exacerbation. Heart failure and recurrent aspiration both place the patient at an increased risk for developing an infection.

COPD exacerbation, recurrent aspiration, heart failure, and pneumonia are all be tied together by the symptoms of shortness of breath, productive cough, and fever, which indicate or can lead to fluid accumulation in the lungs.

 

6.   Which other further investigations do you think would be appropriate?  Why? What results would you expect? What might be expected on this patient’s chest Xray?

·         Pulse oximetry

·         Spirometry

·         Alpha-1-antitrypsin level

·         None of the above

 

A pulse oximetry would be obtained to monitor the patient’s oxygenation levels. The patient has already been diagnosed with COPD, so checking his anti-trypsin levels is redundant. Spirometry would not be used during the time of exacerbation, because the patient already cannot breathe, spirometry at this time would worse the condition. Again, spirometry would have been used in the diagnoses of COPD, or following the exacerbation to monitor decline in lung function. Once the patient has regained his ability to breathe, incentive spirometry may be used to prevent further accumulation of fluid in the lungs, and to monitor lung function. If pneumonia were indeed the diagnosis, fluid accumulation within the lungs would be visible with a chest xray. I think that obtaining a sputum culture would be beneficial in identifying the pathogen causing the infection, as well as blood work to confirm the presence of an infection by checking the white blood cell count.

 

7.   Does JS present with clinical factors that increase risk of severe COPD exacerbations? If so, can you list at least two?

Heart failure, older age, FEV decline, hypoxia and hypercapnia, pulmonary hypertension, use of beta blockers are all risk factors in COPD exacerbation. (Chronic Obstructive Pulmonary Disease, Risk Factors, and Outcome Trials, n.d.)

8.   What would be the best option to improve his symptoms and slow progression?  Would you treat JS as an outpatient or inpatient? Explain your choices.

The best course of treatment for this patient would be to admit him to the hospital, and administer I.V. antibiotics to treat the infection, along with administration of a long-acting bronchodilator to help relieve constriction of the airway and prevent bronchospasm. Expectorants may be used in order to clear the mucus from the airway. Oxygen would be administered, with recurrent arterial blood gases to monitor state of acidosis and to ensure ample oxygenation without CO2 retention. Administration of corticosteroids may also be considered to reduce inflammation. (COPD Exacerbations Management, n.d.)

9.  Would you be concerned that the patient takes a beta blocker? Why?  Advise the patient to stop taking the beta blocker? (Look it up)

There is a reluctance to use beta blockers in patients with COPD for fear of inducing adverse reactions including asthma exacerbation and bronchospasm.

In patients with asthma, beta blockers can cause increased bronchial obstruction and airway reactivity, and resistance to the effects of inhaled or oral beta receptor agonists such as albuterol. While it appears beta-blockers reduce FEV, it is believed for the meantime that the benefit outweighs the risk. (Beta-blockers use in patients with chronic obstructive pulmonary disease and concomitant cardiovascular conditions, n.d.)

10.   What do you think about the possibility of using non-invasive positive pressure ventilation (bi-level positive airway pressure or BiPAP) in this patient?

BiPAP would be considered for this patient. BiPAP is indicated in type II respiratory failure resulting from COPD exacerbation. Type II respiratory failure is characterized by hypoxemia with hypercapnia and acidosis. BiPAP assists patients by reducing effort involved in breathing, resting respiratory muscles, reducing respiratory rate, reducing PaCO2, increasing PaO2, improving alveolar ventilation, and increasing the volume of each breath. (Non-invasive ventilation in COPD exacerbations, n.d.)

 

11. What is the main difference between bi-level positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP)?  What are the indications for using these different modes of non-invasive mechanical ventilation?

CPAP delivers a continuous positive pressure, whereas BiPAP delivers an inhale and an exhale pressure. CPAP is usually used in obstructive sleep apnea, and BiPAP is indicated in respiratory and congestive heart failure. The dual setting of the BiPAP allows the patient to get more air in and out of their lungs. (CPAP vs BiPAP, n.d.)

 

 

 

References

Beta-blockers use in patients with chronic obstructive pulmonary disease and concomitant cardiovascular conditions. (n.d.). Retrieved from US National Library of Medicine : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699954/

 

Chronic Obstructive Pulmonary Disease, Risk Factors, and Outcome Trials. (n.d.). Retrieved from ATS Journals: http://www.atsjournals.org/doi/full/10.1513/pats.200603-094SS#.VktxZ3arSM8

 

COPD Exacerbations Management. (n.d.). Retrieved from US National Library of Medicine : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2111219/

 

CPAP vs BiPAP. (n.d.). Retrieved from American Sleep Association: https://www.sleepassociation.org/cpap-vs-bipap/

 

Non-invasive ventilation in COPD exacerbations. (n.d.). Retrieved from Nursing Times: http://www.nursingtimes.net/non-invasive-ventilation-in-copd-exacerbations/5062992.fullarticle