1. 59-year old male with shortness of breath State University of New York Polytechnic Institute Presented by Francine Bassett

2. Patient & Source of Encounter T.I., 59-year old male Elizabethtown Community Hospital – Emergency Department

3. HPI 59- year old male patient presents to the ER via personal vehicle with c/o shortness of breath x 3 days. Pt reports his illness began on Monday morning. By Monday evening, pt reports he lied down and it became difficult to breath, with sudden onset. He had chest pressure that lasted approximately 30 seconds that went away after he sat up and took a deep breath. He was also clammy. Pt tried to take “cough syrup” once on Tuesday which didn’t work. He hasn’t taken any since then. Denies taking any other medications, antibiotics, or tried other interventions. Pt continues with a dry, non-productive cough, worse when laying flat and at night. Pt states he has been sleeping in the tripod position with pillows since Monday night. Today (Thursday), the school pt works at called the ER stating he was coming in. Upon arrival to the ER, pt admits to constant, non-radiating, mid-sternal chest pressure, worse when lying down, improved by sitting up. Denies pain. Admits to dyspnea, orthopnea, cough, body aches. Denies chills, fever, nausea, vomiting, abd pain, ear pain, sore throat. Denies any recent travel/limited movement. Daily cig Smoker = 10 pack years. Denies ETOH abuse or recreational drugs. Denies any known past medical history. Doesn’t recall last visit to a health care provider. Denies any medication history. Denies receiving flu and pneumonia vaccine. Denies sick contacts.

4. ROS General: Denies fever, chills, night sweats. Skin: Admits to sweating. Ears: Denies ear ache. Nose/sinus: Admits to clear nasal discharge. Denies post nasal discharge, sinus pain or infections. Mouth/throat: Denies sore throat. Respiratory: Admits to pain, dyspnea, orthopnea, wheezing, cough. Denies asthma, bronchitis, COPD, sputum. Cardiac: Admits to pressure, dyspnea. Denies HTN, syncope, edema Peripheral vascular: Denies blood clots. GI: Denies nausea, vomiting, abd pain.

5. History PMHx – Patient denies any known past medical history. – Medications:OTC Cough syrup x1 past Tuesday – unknown name. – Hospitalizations/injuries/accide nts: Denies. – Allergies: Denies allergy to food, latex, environment, or medications. – Immunizations: Denies flu and pneumonia. Family Hx – Denies any familial hx of cardiac, blood disorders, or respiratory problems. Social Hx – Occupational: Maintenance at grade school – Habits: 10 pack year smoker. Denies illicit drug use. Denies ETOH abuse.

6. Physical Exam General appearance: 59-year old acutely ill male, pale, in moderate respiratory distress, sitting upright on stretcher. VS: T98.1, RR 20, P 90, BP 171/70, Spo2 92% RA (on arrival)  97%2LNC Ht/Wt/BMI: 72in/160lb/21.7 Skin: Pale, warm, dry. Absence of rashes. Eyes: Sclera white, anicteric. Ear: EAC’s without drainage or edema. TM’s pearly gray, cone of light 5 o’clock Right, 7 o’clock left. Throat/mouth:. Posterior pharynx pink, without exudates. Uvula midline. Tonsils +1 bilaterally. Neck: Absence of lymphadenopathy. Trachea midline. Chest/lungs: Labored, deep, respirations. AP diameter 1:2. Coarse crackles bases bilaterally. Upper lobes with expiratory wheezes. Using accessory muscles, supraclavicular retractions. Mid-sternal pressure. Resonant to percussion. CV/PV: RRR. S1:S2. No murmurs, gallos, rubs, clicks, heaves, thrills. Absence of carotid bruits. Cap refill <2seconds. Strong 2+ radial and pedal pulses bilaterally. Absence of peripheral edema. Abdomen: Flat. Absence of hepatosplenomegaly. Neurological: Alert and oriented to self, place and time. Speech intact.

7. Differential Diagnosis (so far) DVT Pulmonary Embolism MI CHF Pneumonia Bronchitis COPD/asthma exacerbation

8. Diagnostics/Work-up CXR EKG CBC CMP D-Dimer Troponin BNP

9. Treatment Saline lock 2LNC Oxygen Duoneb (Albuterol/Ipratropium) INH x1 – Short acting bronchodilator/short acting anticholinergic

10. Post-treatment Oxygen: Spo2 92%  97% 2LNC  95% RA at discharge After Duoneb  Wheezes improved upper lobea. Coarse crackles absent. Clear bases bilaterally. VS: BP 148/76, HR 87, Spo2 99% 2LNC, rr 18

11. Diagnostics - Results CXR  No infiltrates or consolidation. Nml. EKG  Sinus rhythm CBC  WNL CMP  WNL D-Dimer  50 (<=250) Troponin  <0.02 BNP  586 (<200)

12. Diagnosis – Rule out DVT Pulmonary Embolism MI CHF Pneumonia Bronchitis COPD/asthma exacerbation

13. Diagnosis Obstructive chronic bronchitis with Exacerbation ICD-9 491.21

14. Etiology Prolonged exposure to bronchial irritants – Smoking, environmental, occupational – Chronic, poorly controlled respiratory allergies – Chronic respiratory infections – Low birth weight (Hollier & Hensley, 2011, p. 576)(Global Initiative for Chronic Obstructive Lung Disease, 2015,p. 6)

15. Incidence 14.2 million people – COPD 12.5 million people – Chronic bronchitis Fourth leading cause of death in United States (Hollier & Hensley, 2011, p. 576)

16. Pathophysiology Inflammatory disease of the mucus membranes of the bronchi Increased amount of sputum throughout part or the entire year. Chronic irritation leads to increase in mucus production Mucus gland hyperplasia and increased risk for infection Airway narrowing and increased airway resistance, fibrosis around bronchioles All these factors result in airway narrowing = obstructive disease (Higginson, 2010, p.107-108)

17. Management Plan Ventolin MDI (Albuterol sulfate) 90mcg 2 puffs INH Q4-6H PRN – Short acting bronchodilator Prednisone taper (corticosteroid) Z-pak Zithromax (Azithromycin) 250mg PO daily x6days – Macrolide Abx

18. Education Minimize exposure to irritants Pneumococcal & influenza vaccine Reduce exposure to persons with respiratory infection Increase fluid intake Pursed lip breathing (if needed) Smoking cessation

19. Follow-up Every 3-6 months for stable disease Maintain close follow-up with patients with acute respiratory infections Review treatment plan with patient at each visit (Hollier & Hensely, 2011,p. 576)

20. References Global Initiative for Chronic Obstructive Lung Disease. (2015). Pocket guide to COPD diagnosis, management, and prevention. Retrieved February 18, 2015 from http://www.goldcopd.org/uploads/users/files/GOLD_P ocket_2015.pdf http://www.goldcopd.org/uploads/users/files/GOLD_P ocket_2015.pdf Higginson, R. (2010). COPD: pathophysiology and treatment. Nurse Prescribing, 8(3), 102-110. Hollier, A., & Hensley,R. (2011). Clinical guidelines in primary care: A reference and review book. Lafayette,LA: Advanced Practice Education Associates.