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

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

1. Severity of breathlessness
2. Sputum production
3. Wheezing
4. Weight loss/anorexia
5. All of the above

• JS current symptoms include the following:
  • Unable to speak in full sentences for the past several hours per wife
  • Cough productive but unknown color of sputum
  • Audible wheezing since last night per wife
  • Mild chest tightness
  • Dyspnea
• His wife has noted no change in his alertness or mental status
• When you inquire, the wife states that JS usually has a cough, worse in the morning, productive of gray sputum, gets short of breath if he walks more then 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.

• Physical examination
  • Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 122 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

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

WRITE THIS ESSAY FOR ME

Tell us about your assignment and we will find the best writer for your paper.

Get Help Now!

1. COPD exacerbation
2. Recurrent aspiration
3. Heart failure
4. Pneumonia
5. Asthma exacerbation

The additional studies you are considering include which of the following?

1. Pulse oximetry
2. Spirometry
3. Alpha-1-antitrypsin level
4. None of the above

• Study results
  • Pulse oximetry 86%
  • Chest x-ray shows hyperinflation and right lower lobe pneumonia
  • You continue his heart failure medications as per his home regimen
    • No need to discontinue the cardioselective beta-blocker

• Factors that increase risk of severe COPD exacerbations
  • Altered mental status
  • At least three exacerbations in the previous 12 months
  • Body mass index of 20 kg per m2 or less
  • Marked increase in symptoms or change in vital signs
  • Medical comorbidities (especially cardiac ischemia, heart failure, pneumonia, diabetes mellitus, or renal or hepatic failure)
  • Poor physical activity levels
  • Poor social support
  • Severe baseline COPD (FEV1/FVC ratio less than 0.70 and FEV1 less than 50 percent of predicted)
  • Underutilization of home oxygen therapy

• Based on this information, JS has the following clinical factors that increase his risk of a severe COPD exacerbation:
  • Marked increase in symptoms and change in his vital signs including a low oxygen saturation
  • a new medical co-morbidity of pneumonia
  • all combined with his severe baseline COPD

 So will you treat JS as an outpatient or inpatient?

• Indications for hospitalization
  • Risk of death from an exacerbation increases with:
    • Development of respiratory acidosis
    • Presence of significant comorbidities,
    • Need for ventilatory support

You determine that JS needs to be hospitalized and while waiting for EMS transport to your local medical center you instruct your nurse to place him on oxygen by nasal cannula. In addition to oxygen, you want to provide which of the following agents via nebulizer?

1. Arformoterol
2. Albuterol
3. Formoterol
4. Budesonide

Upon arrival at the ER, respiratory therapy asks to change albuterol to levalbuterol.  Which of the following are reasons to choose levalbuterol over albuterol?

1. Improved bronchodilation
2. Less hypokalemia
3. Less tachycardia
4. None of the above

Corticosteroids should be delivered by what route in mild to moderate exacerbations of COPD?

1. Inhaled via dry powdered inhaler
2. Nebulized
3. Oral
4. Intravenous

Which of the following are indications for antibiotics in patients with acute exacerbations of COPD?

1. Dyspnea
2. Increased volume of sputum
3. Change in sputum purulence
4. All of the above

• History of Exacerbations
  • Upon questioning his wife, you find out that he has had 5 exacerbations in the past year, three of which were treated with antibiotics and oral steroids
    • Amoxicillin x2 courses, doxycycline x1 course
    • Most recent course 6 weeks ago
    • No hospitalizations within the last 6 months
  • Based on this information, and his chest x-ray findings, you initiate treatment for community acquired pneumonia.