NR601 Week 2 Discussion (dq1+dq2) Latest 2020 JULY

NR601 Primary Care of the Maturing and Aged Family

Week 2 Discussion

DQ1 COPD Case Study Part 1

Purpose

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’ 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.

Activity Learning Outcomes

Through this discussion, the student will demonstrate the ability to:

Demonstrate competence in the evaluation and management of common respiratory problems (WO 2.1) ?(CO,2,3,4,5)

Distinguish 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.?(WO 2.2) (CO 2,4) 

Interpret pulmonary function test results. (WO 2.3) (CO 2, 4)

Case Study – Part 1

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.

History of Present Illness
Onset	6 months
Location	Chest
Duration	Cough is intermittent but frequent, worse in the AM
Characteristics	Productive; whitish-yellow phlegm
Aggravating factors	Activity
Relieving factors	Rest
Treatments	Tried Robitussin DM without relief of symptoms  ?
Severity	Unable to walk > 20ft without stopping to catch his breath. Last year at this time he routinely walked 1 mile per day without difficulty
Review of Systems (ROS)
Constitutional	Denies fever, chills, or weight loss?
Ears	Denies otalgia and otorrhea
Nose	Denies rhinorrhea, nasal congestion, sneezing or post nasal drip.
Throat	Denies ST and redness
Neck	Denies lymph node tenderness or swelling
Chest	Describes a persistent productive cough upon wakening for the last 6 months. Color of phlegm is usually white-yellowish. Shortness of breath with activity.
Cardiovascular	Denies chest pain and lower extremity edema

 

History  Medications  Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamin daily  PMH  Primary hypertension  PSH  Cholecystectomy, appendectomy  Allergies  Penicillin (hives)  Social  Married, 3 children  Senior accountant at a risk management firm  Habits  Former smoker (20 pack-year), quit “cold turkey” when father died; Denies alcohol or illicit drug use.  FH  Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker)  Mother is alive (osteoporosis)   Healthy siblings

 Physical exam reveals the following:

Physical Exam  Constitutional  Adult male in NAD, alert and oriented, able to speak in full sentences   VS  Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA  Head  Normocephalic  Ears  Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.  Nose  Nares patent. Nasal turbinates clear without redness or edema. Nasal drainage is clear.  Throat  Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.  Neck  Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. No JVD  Cardiopulmonary  Heart 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.  Abdomen  Soft, non-tender. No organomegaly

Requirements/Questions:

Briefly 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.

Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement (2-3 sentences) of pathophysiology for each.

Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.

Rank the differential in order of most likely to least likely.

Identify 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.

DQ2 COPD Case Study Part 2

Purpose

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’ 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.

Activity Learning Outcomes

Through this discussion, the student will demonstrate the ability to:

Demonstrate competence in the evaluation and management of common respiratory problems (WO 2.1) (CO 2,3,4,5)

Distinguish 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.?(WO 2.2) (CO 2,4) 

Interpret pulmonary function test results. (WO 2.3) (CO 2, 4)

Case Study – Part 2

You 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

CXR Result:

No acute infiltrates or consolidations are seen. Cardiac and mediastinal silhouettes are normal. No hilar enlargement is evident. Osseous thorax is intact.

Spirometry Results:

Pre-Bronchodilator				Post-Bronchodilator
	Predicted	Actual	%Predicted	Actual	% Predicted	% Change
FVC (L)	4.52	3.01	67	3.08	68	2
FEV1 (L)	3.40	1.58	46	1.60	47	1
FEV1/FV	.75	.52	—	.52	—	0

 

Requirements/Questions:

What 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)

Identify the corresponding ICD-10 code.

Provide a treatment plan for this patient’s primary diagnosis which includes:

Medication*

Any additional testing necessary for this particular diagnosis*

Patient education

Referral

Follow up

 Provide an active problem list for this patient based on the information given in the case.

 Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBP argument for each treatment or testing decision.

*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based practice  (EBP) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.

Over-the-counter (OTC) and RXs must be written in full as if handing a prescription to the patient in the office.??

Example:??

Amoxicillin 500 mg capsule?

1 tab po BID q 10 days?

Disp #20 no refills??