NR 601 Week 2: COPD Case Study Part 2<\/p>\n
This assignment is about a 62-year-old Caucasian male presenting to the clinic with complaints of persistent cough and a recent onset of breath shortness. Your work is to assess the patient to discover additional information, diagnose the patient then devise a management plan for the patient.<\/p>\n
Week 2: COPD Case Study Part 2 (Initial post due Thursday, faculty and peer responses due Sunday)<\/p>\n
Case Study \u2013 Part 2
\nYou ordered a CXR and spirometry at the previous visit and he returns today to review the results. Physical exam and symptoms are unchanged since last visit. Vital signs at this visit are: Temp-98.3, P-68, RR-20, BP 152\/90, Height 68.9in., Weight 258 pounds, O2sat 94% on RA<\/p>\n
CXR Result:<\/p>\n
No acute infiltrates or consolidations are seen. Cardiac and mediastinal silhouettes are normal. No hilar enlargement is evident. Osseous thorax is intact.<\/p>\n
Spirometry Results:<\/p>\n
Pre-Bronchodilator\tPost-Bronchodilator
\nPredicted\tActual\t%Predicted\tActual\t% Predicted\t% Change
\nFVC (L)\t4.52\t3.01\t67\t3.08\t68\t2
\nFEV1 (L)\t3.40\t1.58\t46\t1.60\t47\t1
\nFEV1\/FV\t.75\t.52\t\u2014\t.52\t\u2014\t0<\/p>\n
Requirements\/Questions:
\nWhat is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
\nIdentify the corresponding ICD-10 code.
\nProvide a treatment plan for this patient\u2019s primary diagnosis which includes:
\nMedication*
\nAny additional testing necessary for this particular diagnosis*
\nPatient education
\nReferral
\nFollow up
\nProvide an active problem list for this patient based on the information given in the case.
\nAre there any changes that you would also make to this patient\u2019s overall treatment plan at this time? Must provide an EBP argument for each treatment or testing decision.
\nOver-the-counter (OTC) and RXs must be written in full as if handing a prescription to the patient in the office.<\/p>\n
ORDER NR 601 Week 2: COPD Case Study Part 2
\nExample:<\/p>\n
Amoxicillin 500 mg capsule<\/p>\n
1 tab po BID q 10 days<\/p>\n
Disp #20 no refills<\/p>\n
DISCUSSION CONTENT
\nCategory\tPoints\t%\tDescription
\nApplication of Course Knowledge\t15\t30%
\nStudent chooses one appropriate diagnosis for the patient; AND
\nDiagnosis is supported with strong pertinent positive and negative subjective and objective data from parts 1 & 2; AND
\nThe ICD code for the diagnosis is correct; AND
\nTreatment plan for primary diagnosis includes medication, additional testing, patient education, and referral; AND
\nPrescription and OTC medications are written appropriately as a RX and all components are correct; AND
\nTreatment decisions (medication, additional testing, referrals) are supported with appropriate EBP arguments; AND
\nAn accurate problem list is presented based on case information; AND
\nStudent discusses changes (or not) to the overall treatment plan for the patient for pertinent issues; AND
\nAn appropriate F\/U plan is provided
\n(9 critical elements)<\/p>\n
Week 2: COPD Case Study Part 1 Example
\nPurpose<\/p>\n
Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice. The purpose of this activity is to develop students\u2019 clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group.<\/p>\n
Activity Learning Outcomes<\/p>\n
Through this discussion, the student will demonstrate the ability to:<\/p>\n
Demonstrate competence in the evaluation and management of common respiratory problems (WO 2.1) \u202f(CO,2,3,4,5)
\nDistinguish between obstructive and restrictive lung disease (CO 2, 4) Develop a management plan for the case study patient based on identified primary, secondary and differential diagnoses.\u202f(WO 2.2) (CO 2,4)
\nInterpret pulmonary function test results. (WO 2.3) (CO 2, 4)
\nDue Date:<\/p>\n
Student enters initial post to part one by 11:59 p.m. MT on Tuesday; responds substantively to at least one topic-related post of a peer including evidence from appropriate sources AND all direct faculty questions in parts one by Sunday, 11:59 p.m. MT.<\/p>\n
A 10% late penalty will be imposed for discussions posted after the deadline on Tuesday 11:59pm MT, regardless of the number of days late. NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0).<\/p>\n
Total Points Possible: 50<\/p>\n
Case Study \u2013 Part 1
\nDate of visit: November 20,<\/p>\n
A 62 year-old Caucasian male presents to the office with persistent cough and recent onset of shortness of breath. Upon further questioning you discover the following subjective information regarding the chief complaint.<\/p>\n
History of Present Illness
\nOnset\t6 months
\nLocation\tChest
\nDuration\tCough is intermittent but frequent, worse in the AM
\nCharacteristics\tProductive; whitish-yellow phlegm
\nAggravating factors\tActivity
\nRelieving factors\tRest
\nTreatments\tTried Robitussin DM without relief of symptoms<\/p>\n
Severity\tUnable to walk > 20ft without stopping to catch his breath. Last year at this time he routinely walked 1 mile per day without difficulty
\nReview of Systems (ROS)
\nConstitutional\tDenies fever, chills, or weight loss
\nEars\tDenies otalgia and otorrhea
\nNose\tDenies rhinorrhea, nasal congestion, sneezing or post nasal drip.
\nThroat\tDenies ST and redness
\nNeck\tDenies lymph node tenderness or swelling
\nChest\tDescribes a persistent productive cough upon wakening for the last 6 months. Color of phlegm is usually white-yellowish. Shortness of breath with activity.
\nCardiovascular\tDenies chest pain and lower extremity edema
\nORDER NR 601 Week 2: COPD Case Study Part 2 and Part 1
\nHistory
\nMedications\tMetoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamin daily
\nPMH\tPrimary hypertension
\nPSH\tCholecystectomy, appendectomy
\nAllergies\tPenicillin (hives)
\nSocial\tMarried, 3 children
\nSenior accountant at a risk management firm<\/p>\n
Habits\tFormer smoker (20 pack-year), quit \u201ccold turkey\u201d when father died; Denies alcohol or illicit drug use.
\nFH\tFather died of MI & CHF at age 59 years (diabetes, hypertension, smoker)
\nMother is alive (osteoporosis)<\/p>\n
Healthy siblings<\/p>\n
Physical exam reveals the following:<\/p>\n
Physical Exam
\nConstitutional\tAdult male in NAD, alert and oriented, able to speak in full sentences
\nVS\tTemp-98.1, P-66, RR-20, BP 156\/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA
\nHead\tNormocephalic
\nEars\tTympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.
\nNose\tNares patent. Nasal turbinates clear without redness or edema. Nasal drainage is clear.
\nThroat\tOropharynx moist, no lesions or exudate. Tonsils \u00bc bilaterally. Teeth in good repair, no cavities noted.
\nNeck\tNeck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. No JVD
\nCardiopulmonary\tHeart S1 and S2 with no murmurs, noted. Lungs clear to auscultation bilaterally with faint forced expiratory wheezes in bilateral bases. Respirations unlabored. Legs without edema.
\nAbdomen\tSoft, non-tender. No organomegaly<\/p>\n
Requirements\/Questions:
\nBriefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. May use approved medical abbreviations. Avoid redundancy and irrelevant information.
\nProvide a differential diagnosis (minimum of 3) which might explain the patient\u2019s chief complaint along with a brief statement (2-3 sentences) of pathophysiology for each.
\nAnalyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
\nRank the differential in order of most likely to least likely.
\nIdentify any additional tests and\/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based practice (EBP) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBP evidence.<\/p>\n
DISCUSSION CONTENT
\nCategory\tPoints\t%\tDescription
\nApplication of Course Knowledge\t15\t30%\t1. A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND
\n2. Three (3) appropriate diagnoses in the differential are presented which can explain the patient\u2019s chief complaint; AND<\/p>\n
3. A brief statement of pathophysiology is included for each diagnosis; AND<\/p>\n
4. Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND<\/p>\n
5. The differential is ranked in order from most likely to least likely; AND<\/p>\n
6. Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND<\/p>\n
7. Testing decisions are well supported with EBP arguments that are in-line with the clinical scenario and appropriate for the primary care setting<\/p>\n
(7 critical elements)<\/p>\n
Support from Evidence-Based Practice (EBP)\t15\t30%\t1. Discussion post is supported with appropriate, scholarly sources; AND
\n2. Sources are published within the last 5 years (unless it is the most current CPG); AND<\/p>\n
3. Reference list is provided and in-text citations match; AND<\/p>\n
4. All testing decisions are fully supported with an appropriate EBP argument<\/p>\n
(4 critical elements)<\/p>\n
Interactive Dialogue\t10\t20%\t1. Student provides a substantive* response to at least one topic-related post of a peer; AND
\n2. Evidence from appropriate scholarly sources are included; AND<\/p>\n
3. Reference list is provided and in-text citations match; AND<\/p>\n
4. Student responds to all direct faculty questions<\/p>\n
(*) A substantive post adds new content or insights to the discussion thread and information from student\u2019s original post is not reused in peer or faculty response<\/p>\n
(4 critical elements)<\/p>\n
Total CONTENT Points= 40 pts
\nDISCUSSION FORMAT
\nCategory\tPoints\t%\tDescription
\nOrganization\t5\t10%\t1. Case study response is presented in a logical format, AND
\n2. Responses are in sequence with the numbered questions AND<\/p>\n
3. The case study response is understandable and easy to follow AND<\/p>\n
4. All responses are relevant to the case topic<\/p>\n
(4 critical elements)<\/p>\n
Grammar, Syntax, Spelling & Punctuation\t5\t10%\tDiscussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors*<\/p>\n
Total FORMAT Points= 10 pts
\nDISCUSSION TOTAL= 50 pts<\/p>\n
Search entries or author Filter replies by unread Unread Collapse replies Expand replies<\/p>\n
Subscribed<\/p>\n
ReplyReply to Week 2: COPD Case Study Part 1 (Initial post due Tuesday, faculty and peer responses due Sunday)<\/p>\n
Jan 12, 2020Jan 12 at 8:06am<\/p>\n
Manage Discussion Entry<\/p>\n
Summary<\/p>\n
Patient is a 62-yr. old male with a cc of frequent productive cough for the past 6 months that is worse in the morning. The cough is worse with activity and relieved by rest. He has been experiencing decreased activity tolerance. Last year he routinely walked a mile a day and now he can\u2019t walk over 20 feet without having to stop due to being short of breath. He has taken Robitussin DM without any relief in symptoms. He has a history of HTN for which he takes Toprol XL daily. He also takes a multivitamin daily. He is a former smoker of 20 pack-year who denies alcohol or illicit drug use. His father died at age 59 of MI & CHF. His father had a history of diabetes, HTN, and smoking. His mother is alive with a history of osteoporosis. His siblings are healthy.<\/p>\n
ROS\u2013 Patient denies any fever, chills, or weight loss. He has no nasal congestion or post-nasal drip. Patient has shortness of breath with activity. He reports having a persistent productive cough with with-yellowish phlegm. Patient denies any chest pain or edema in his lower extremities.<\/p>\n
PE-Upon exam patient is afebrile with a BP of 156\/94, HR 66, RR 20 and o2 sat 94% on room air. His BMI is 39.23. No has clear nasal drainage. S1 and S2 with no murmurs. Lungs are clear bilaterally with faint forced expiratory wheezes in bilateral bases. Respirations unlabored. Legs without edema.<\/p>\n
Differential Diagnosis ranked most likely to least likely:<\/p>\n
#1 COPD<\/p>\n
COPD is a persistent respiratory condition that is common and preventable. Cigarette smoking is the most significant risk factor. COPD is characterized by chronic airflow limitation due to inflammation. Structural changes and destruction of the lung parenchyma take place leading to loss of alveolar attachments to the small airways and a reduction in lung elastic recoil. These changes decrease the ability of the airways to remain open during expiration (GOLD, 2020).<\/p>\n
Analysis:<\/p>\n
Pertinent positives- chronic cough (6 months), progressive decrease in activity tolerance due to shortness of breath wheezing, history of smoking and was exposed to smoke as a child since his father smoked<\/p>\n
Pertinent negatives-afebrile, nasal turbinates without redness or edema, Oropharynx moist, no lesions or exudate, denies sore throat, no family history of COPD<\/p>\n
#2 Asthma<\/p>\n
Asthma is a chronic inflammatory disorder of the airways. The inflammation is associated with bronchial hyperresponsive, constriction of the airways, and variable airflow obstruction that is reversible. This causes wheezing, shortness of breath, chest tightness, and coughing. Contributing factors include exposure to allergens, environmental pollution, tobacco smoke, and obesity (GINA, 2019)).<\/p>\n
ORDER NR 601 Week 2: COPD Case Study Part 2
\nAnalysis:<\/p>\n
Pertinent positives- wheezing, on beta blocker, obesity, previous smoker and exposed to smoke as a child since father smoked, cough worse in morning, activity intolerance due to shortness of breath<\/p>\n
Pertinent negatives-respirations unlabored, no occupational exposure (senior accountant), no known environmental allergies, no family history of asthma<\/p>\n
#3 Heart Failure<\/p>\n
Heart failure (HF) is a complex syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. Risk factors include HTN, elevated cholesterol, obesity, diet, and physical inactivity. Symptoms of HF include dyspnea, fatigue, fluid retention, and exercise intolerance. These clinical symptoms result from disorders of the pericardium, myocardium, endocardium, heart valves, or from certain metabolic abnormities (Yancy et al., 2013).<\/p>\n
Analysis:<\/p>\n
Pertinent positives- shortness of breath, progressive activity intolerance, persistent productive cough, wheezing, HTN (155\/94) Risk factors present: male, 62 yrs. old, history of HTN and smoking- Father has history CHF<\/p>\n
Pertinent negatives- no edema in extremities, no JVD, heart rate 66 (no tachycardia)<\/p>\n
Additional test or procedures:<\/p>\n
Pulse oximetry- a simple non-invasive way to assess the patient\u2019s arterial oxygen saturation. (GOLD, 2020). A decreased oxygen saturation may be present with COPD, Asthma, or HF. It is important to evaluate to determine if supplemental oxygen is needed.<\/p>\n
Spirometry- Airflow limitation can be measure with spirometry. It is the most widely available and reproducible test of lung function (GOLD, 2020). This is a simple lung function test that can be used to diagnose asthma or COPD. An improvement of 12% and 200lm in the FEV1\/FVC ratio after a bronchodilator indicates reversible airway obstruction. This would be helpful to differentiate asthma from COPD (Bringham & West, 2015).<\/p>\n
Chest x ray- A chest-xray will not diagnose asthma or COPD, but it will be used exclude the presence of some other pulmonary or cardiac diseases (GOLD, 2020). It can show heart enlargement and fluid in the lungs which would help diagnose HF.<\/p>\n
CBC- A CBC will check for anemia, (which occurs in advanced COPD with hypoxemia), infection, or eosinophilia which would indicate an allergic or asthmatic component (GOLD, 2020).<\/p>\n
BNP-A lower BNP can exclude the presence of HF and a higher result has a reasonably high predictive value to diagnose HF (Yancy et al., 2013).<\/p>\n
Reference:<\/p>\n
Bringham, E. West, N., (2015). Diagnosis of asthma: Diagnostic testing. International Forum of Allergy & Rhinology, 5 (1). 527-530. doi: 10.1022\/air.21597<\/p>\n
Global Initiative for Asthma. Management and prevention for adults and children over 5 years old. (2019). Retrieved from https:\/\/ginasthma.org\/gina-reports\/<\/p>\n
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2020). Retrieved from https:\/\/goldcopd.org\/wp-content\/uploads\/2019\/12\/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf<\/p>\n
Yancy, C. W., Jessup, M., Butler, J., Drazner, M., Geraci, S., Januzzi, J., Kasper, E., Masoudi, F., McMurray, J., Peterson, P., Sam, F., Tang, W., Wilkoff, B. (2013). 2013 ACCF\/AHA guideline for the management of heart failure. A report of the American College of Cardiology Foundation\/ American Heart Association task force on practice guidelines. Retrieved from http:\/\/www.onlinejacc.org\/content\/accj\/62\/16\/e147.full.pdf?_ga=2.28012988.1211871446.1578704549-315720946.1563672617<\/p>\n
Module 5 Assignment \u2013 Information Retrieval Paper, Part 3 COPD
\nSubmit by 2359 Saturday at the close of Module 5 (Last week of the course)<\/p>\n
Name\t\tDate:
\nOverview: \u201cInformation Retrieval Paper: Part 3\u201d<\/p>\n
This week, you will complete Part 3 of the Information Retrieval Paper, which you worked on in Module 3 and 4. You are using the template provided, do not create a new word document.<\/p>\n
So far, you have developed a research question, identified the PICO components of your research question, included your rationale for selecting your research question, created a title page for your paper in APA format, located three peer-reviewed articles, summarized each article in APA format, and critically analyzed the articles.<\/p>\n
In this module, you will summarize and synthesize the key points of the peer-reviewed, evidence-based articles and develop a reference page in APA format.<\/p>\n
Be sure to review the previous assignments that relate to the Information Retrieval Paper. Incorporate your Coach\u2019s suggestions and corrections so you won\u2019t make the same mistakes again in this last section of the Information Retrieval Paper.<\/p>\n
Performance Objectives:<\/p>\n
Synthesize the key points of peer-reviewed, evidence-based articles.
\nDevelop a reference page in APA format.
\nUse correct grammar, punctuation, and American Psychological Association (APA) format in writing professional papers.
\nRubric<\/p>\n
Use this rubric to guide your work \u201cInformation Retrieval Paper, Part 3.\u201d<\/p>\n
Task
\n\uf0ea<\/p>\n
Accomplished\tProficient\tNeeds Improvement\tMissing Information
\nWeek 5 Application:
\n\u201cInformation Retrieval Paper: Part 3\u201d (100 points total)<\/p>\n
Task #1:<\/p>\n
Conclusion: Summarize Key Points (Total 60 points)<\/p>\n
Key findings are identified and discussed relating to the identified research question studied. Well written with at least 3 sentences per topic. Scholarly writing is fully observed. (60 points)<\/p>\n
Key findings are identified and minimally linked to the identified research question studied. Two sentences are written per topic and scholarly writing is predominately observed. (40 points)\tKey findings are not fully identified or discussed as related to the peer research question. One sentence per topic is noted and scholarly writing is not observed. (20 points)<\/p>\n
Does not complete.
\n(0 points)<\/p>\n
Task #2:
\nReference Page and In-text Citations<\/p>\n
(Total 40 points)<\/p>\n
Correct Grammar and APA Format are graded heavily.<\/p>\n
References are cited in APA format, alphabetized and complete.
\n(30 points)<\/p>\n
Uses 3 properly formatted in-text citations to support thoughts.<\/p>\n
(10 points)<\/p>\n
Uses correct mechanics and APA format in writing professional papers (1-2 APA errors).
\n(25 points)<\/p>\n
Uses 2 properly formatted in-text citations to support thoughts OR 1-2 APA errors r\/t citations<\/p>\n
(7 points)<\/p>\n
3-4 APA and\/or grammatical errors noted.<\/p>\n
(15 points)<\/p>\n
Uses 1 properly formatted in-text citations to support thoughts OR 3-4 APA errors r\/t citations<\/p>\n
(3 points)<\/p>\n
Does not use correct mechanics and\/or APA format (more than 5 APA and grammatical errors).
\n(0 points)<\/p>\n
No use of in-text citations to support thoughts OR >5 APA errors r\/t citations<\/p>\n
(0 points)<\/p>\n
Week 5 Application
\nInformation Retrieval Paper: Part 3<\/p>\n
In this week\u2019s assignment, you will complete your Information Retrieval Paper. Review the outline for the entire assignment before your begin.<\/p>\n
APA Format Elements\tTimeline
\nTitle Page in APA format\tCompletion Timeline
\nAPA format
\nCitations in the body of the paper<\/p>\n
Headings<\/p>\n
Applicable each time sections are submitted
\nWriting style
\nGrammar<\/p>\n
Spelling<\/p>\n
Paragraphs of at least three well-written sentences<\/p>\n
Organization and flow<\/p>\n
Applicable each time sections are submitted
\nContent Criteria\tTimeline
\nIntroduction:
\nIdentification of clinical problem in a workplace setting<\/p>\n
Research question stated correctly<\/p>\n
Rationale for question<\/p>\n
Title page<\/p>\n
Completed Module 3
\nSummary of 3 peer-reviewed articles
\nOverview: Where did you search? How did you decide on the 3 articles?<\/p>\n
3 article summaries<\/p>\n
Completed Module 3
\nCritical Analysis
\nCompleteness of analysis<\/p>\n
Completed Module 4
\nConclusion
\nSynthesis of key points for the 3 articles<\/p>\n
To be completed Module 5 (now)
\nReference Page
\nAlphabetized<\/p>\n
Sources cited in APA format<\/p>\n
References complete<\/p>\n
To be<\/p>\n","protected":false},"excerpt":{"rendered":"
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