Miami Dade Chronic Obstructive Pulmonary Disease Management Case Study Paper APA style After reviewing the case study, you must create a care/treatment

Miami Dade Chronic Obstructive Pulmonary Disease Management Case Study Paper APA style

After reviewing the case study, you must create a care/treatment plan for the patient. Please see the attached file for the case study.

Your paper must include the following:

1. Identify and describe two barriers to self-management.

2. Define the short term goals (must be measurable and obtainable).

3. Define your plan/intervention for the patient.

4. Provide evidence-based rationale for your interventions.

Below is a list of Barriers to Self-Management that can be used as a guide:

Formatting requirements:a. Title page: needs to include name, case study title, course name, and date.b.
Double-spaced Times New Roman 12-point font Word Document.c.
Page number located at the bottom right corner of the page. d. You must have a minimum of 3 references.
All references should be in APA style.e.
Separate reference page.f. 3-4 pages in length not including title page and reference page.Instructions: RESPCARE 497
COPD Case Study
CHIEF COMPLAINT: Patient complains of “constant coughing, 24 hours per day”.
HPI: 66 year old white male who is here for his COPD and his severe cough. Patient complains of
problems with his breathing present over the past year. He states he had the flu about a year ago and
that his symptoms of shortness of breath and cough began after this. He didn’t have breathing problems
prior to this. He has a frequent cough productive of white sputum. He denies any hemoptysis and
denies any purulent sputum. He states he may have occasional coughing paroxysms that may last up to
10 minutes, and sometimes may feel lightheaded or pre-syncopal with this. He has never had actual
syncope associated with his cough. He has frequent wheezing. He has had several episodes of
pneumonia in the past, states he had a right-sided pneumonia with an empyema requiring surgical
drainage many years ago. He states he had a history of asthma in childhood. He attributes some of his
respiratory problems to exposure to paints and solvents used in the past in his work as an artist. He
estimates he can walk up to 100-150 yards now before he might have to stop and catch his breath. He
states he was not limited with normal walking 2 years ago. He will notice increased symptoms of cough,
wheezing and dyspnea with physical activity. He denies any other exacerbating factors, denies any
increased symptoms with smoke, dust, odors or perfumes, and states his breathing feels better if he is
breathing cold air. He does state that he had increased symptoms this summer when the smoke from
the forest fires was heavy in the valley. He denies problems with nasal congestion or postnasal drip. He
denies heartburn. He denies any choking spells or difficulty with swallowing when drinking or eating.
States he is using the Spiriva once a day, Symbicort bid (without spacer), neb prn (gave himself one 1 hr.
before our appt) and albuterol 15-20 x daily. He states he is definitely SOB and it is not his anxiety
driving his symptoms. Pt states he is a “poly extreme athlete (wears a wingsuit and jumps off the
mountain) and an artist” and has to have his lungs working because he has a trip planned to go to
Pakistan for a jump.” He also discussed having to “avoid the Taliban while kayaking a river, which may
be hard to do….”
He has been given some short courses of prednisone in the past, states his breathing is “40-50% better”
on prednisone, but states it caused him to develop significant lower extremity edema. He doesn’t recall
trying any other medications for his breathing problems. He has been to the ER for breathing problems
7 times since January of this year.
Pets in the home include 2 small dogs. He does not keep birds as pets, does not feed livestock, does not
have a hot tub, and denies any mold or water damage in his home. He has a history of cigarette use of
1/2 PPD ×20 years, and quit smoking cigarettes about a year ago, states he still occasionally smokes a
pipe, although patient has strong smell of cigarette smoke at today’s visit. Patient complains of
significant difficulty with sleeping. He usually goes to bed around 10 PM and falls asleep within 10
minutes. He gets up for the day between 7-8 AM. He complains of frequently waking up during the
night due to coughing or infrequently due to nocturia. He estimates he wakes up 8-10 times during the
night, and usually will fall asleep again fairly quickly once the coughing resolves. He does complain of
some increased cough when he lays flat, and has been sleeping propped up using 6 pillows over the past
3-4 months. He states Tessalon Perles causes diarrhea. He has noted some improvement and control of
his cough with the codeine cough syrup and requests a refill on this. Has some anxiety over his physical
health problems. He is using 02 at 2 lpm NOC, but does not use with exertion because the tanks are too
cumbersome to pack around.
1
PMH:
1. Bipolar disorder
2. Chronic obstructive lung disease
3. Coin lesion of lung
4. Abdominal aortic aneurysm
5. Hypercholesterolemia
6. Reactive airways dysfunction syndrome
7. Essential tremor
8. Postural Hypotension
9. Chronic Kidney Disease, Unspecified
10. Impotence of organic origin
11. Migraine, unspecified, without mention of Intractable Migraine
12. Paroxysmal supraventricular tachycardia
13. Lumbar Radiculopathy
14. Ulnar Neuropathy
15. Hypertension
16. Parkinson Disease
17. Chronic hepatitis C without mention of hepatic coma
18. TOBACCO USE DISORDER
19. CARDIAC DYSRHYTHMIAS NEC
20. BIPOLAR AFFECTIVE NOS
Tobacco use: Cigarettes 1/2 PPD for a total of about 20 years, states he stopped and restarted smoking
multiple times over his lifetime. He still smokes an occasional pipe, but states he doesn’t inhale.
Alcohol use: He denies alcohol use.
Family History: Patient’s father died of some type of cancer in his bones. His mother also died of some
type of cancer in her bones. No other family members have significant lung disease.
Social History: lives independently, active painter, states that he is “the next Jackson Pollack.”
Exercise: difficulty ambulating, has fallen due to oxygen tubing recently – minor injuries
Childhood Illness: Patient states he had asthma in childhood.
Military Service: ARMY
Occupation: The patient was in the Army as a tanker, did go to Vietnam. As a civilian he has worked
designing and doing some landscaping work, but states he mainly has worked as an artist.
Surgical Hx: Right chest surgery due to an empyema many years ago. Distant appendectomy. Bilateral
or lumbar nerve transpositions.
Allergies: Allergies/ADR
VICODIN, HYDROCODONE/POTASSIUM GUAIACOLSULFONATE, TYLENOL WITH CODEINE NO.1
ATARAX, PROZAC 20MG CAPSULE, RISPERIDONE
Medications: Active Outpatient Medications (including Supplies):
Active Outpatient Medications
Status
=========================================================================
1) ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL INHALE 2 PUFFS ACTIVE
BY ORAL INHALATION EVERY FOUR HOURS IF NEEDED FOR
SHORTNESS OF BREATH OR WHEEZING
2) ALBUTEROL SO4 0.083% INHL 3ML USE 1 NEB (3 ML)
ACTIVE (S)
2
NEBULIZED EVERY FOUR HOURS IF NEEDED FOR BREATHING
3) AMLODIPINE BESYLATE 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
EVERY DAY FOR HIGH BLOOD PRESSURE *AVOID GRAPEFRUIT
PRODUCTS
4) ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE (S)
DAY TO PREVENT HEART ATTACK
5) ATORVASTATIN CALCIUM 80MG TAB TAKE ONE TABLET BY
ACTIVE
MOUTH EVERY DAY FOR CHOLESTEROL -LIMIT USE OF
GRAPEFRUIT PRODUCTS
6) AZITHROMYCIN 250MG TAB TAKE TWO TABLET BY MOUTH EVERY ACTIVE
DAY FOR INFECTION
7) BENZONATATE 100MG (TESSALON PERLES) TAKE TWO CAPSULES ACTIVE
BY MOUTH EVERY 12 HOURS IF NEEDED FOR SEVERE COUGH
*DO NOT BREAK OR CRUSH*
8) BUDESONIDE 80/FORMOTEROL 4.5MCG 120D INH INHALE 2 ACTIVE
PUFFS BY MOUTH TWICE A DAY TO PREVENT SHORTNESS OF
BREATH AND WHEEZING *RINSE MOUTH AFTER USE*
9) CARBIDOPA 50/LEVODOPA 200MG SA TAB TAKE 1 TABLET BY ACTIVE
MOUTH EVERY MORNING AND AT NOON FOR PARKINSON’S
SYMPTOMS
10) CARBIDOPA/LEVODOPA 25/100 TAB TAKE 1 TABLET BY MOUTH ACTIVE
FOUR TIMES A DAY FOR PARKINSON’S SYMPTOMS
11) CODEINE 10MG/GUAIFENESIN 100MG/5ML SYRUP TAKE 2
ACTIVE
TEASPOONSFUL BY MOUTH FOUR TIMES A DAY FOR COUGH
12) DIAZEPAM 5MG TAB TAKE 1 TABLET (5MG) BY MOUTH AT
ACTIVE
BEDTIME FOR INSOMNIA
13) DOXYCYCLINE HYCLATE 100MG CAP/TAB TAKE ONE
ACTIVE
CAPSULE/TABLET BY MOUTH EVERY 12 HOURS
14) ENTACAPONE 200MG TAB TAKE ONE TABLET BY MOUTH FOUR ACTIVE
TIMES A DAY FOR PARKINSONS DISEASE
15) FUROSEMIDE 20MG TAB TAKE ONE-HALF TABLET BY MOUTH ACTIVE
EVERY MORNING FOR EXTRA FLUID (WATER PILL)
16) GUAIFENESIN 600MG SA TAB TAKE ONE TABLET BY MOUTH ACTIVE
TWICE A DAY TO LOOSEN CONGESTION *DO NOT BREAK OR
CRUSH*
17) LAMOTRIGINE 25MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE
MORNING FOR MOOD STABILIZATION
18) LITHIUM CARBONATE 150MG CAP TAKE THREE CAPSULES BY ACTIVE (S)
MOUTH AT BEDTIME FOR MOOD
19) NYSTATIN 100000 UNT/ML SUSP TAKE 5ML (1 TEASPOONFUL = ACTIVE
500,000 UNITS) BY MOUTH FOUR TIMES A DAY SWISH AND
SWALLOW FOUR TIMES DAILY
20) PREDNISONE 20MG TAB TAKE TWO TABLET BY MOUTH EVERY ACTIVE
DAY FOR 5 DAYS, THEN TAKE ONE AND ONE-HALF TABLET
EVERY DAY FOR 3 DAYS, THEN TAKE ONE TABLET EVERY
DAY FOR 3 DAYS, THEN TAKE ONE-HALF TABLET EVERY DAY
FOR 3 DAYS TAKE WITH FOOD
21) TIOTROPIUM 18MCG INHL CAP 30 INHALE 1 CAPSULE BY ORAL ACTIVE
3
INHALATION EVERY DAY BREATHE IN THE CONTENTS OF ONE
CAPSULE PER THE MOUTHPIECE AS INSTRUCTED
22) TRAZODONE HCL 50MG TAB TAKE ONE TABLET BY MOUTH AT
BEDTIME FOR SLEEP NOTE INCREASED DOSE
ACTIVE
REVIEW OF SYMPTOMS:
Weight is stable, frequent fatigue, orthopnea with some increased shortness of breath but mainly
increased cough when lying flat, states he sleep propped up on 6 pillows for the past 3-4 months. Pedal
and ankle edema in the last few months which he attributes to prednisone therapy. Some diarrhea
while taking Tessalon, nocturia occasionally, no more than once per night, All other negative
PHYSICAL EXAM
DATE/TIME
TEMP PULSE RESP BP
PAIN WEIGHT PO2
12/15/15 @ 0834
111
178/118
12/15/15 @ 0831 97
112 18
157/105 5
217 95
12/7/15 @ 0821
94
156/100
HOME 02 Evaluation:
Current Rx: 2 lpm NOC and with exertion
Equipment: concentrator, standard regulator & tanks
Resting oximetry on RA
94% SpO2
Ambulatory oximetry on RA
85% SpO2 HR 122
NOC oximetry on RA:
#1
Total time ……………..4:51:20
Time with Sp02
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