While working with your family medicine preceptor you are scheduled to see Mr. John Barley, a 58-year-old male who has sought medical attention only rarely in the past 10 years. He comes to the office today because of a progressively worsening cough and shortness of breath during the previous month.
Before you and your preceptor, Dr. Wilson, enter the room to meet Mr. Barley, Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.
You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you.” Mr. Barley says, “Sure, anyone working with Dr. Wilson is OK by me.”
“I understand you have a cough and shortness of breath. Can you tell me more about it?”
“I’ve had a bad cough, mainly in the morning, last winter and this winter. When I cough, this whitish phlegm comes up.”
OK. Have you noticed anything else that seems to be related to the cough? Things like weight loss, chest pain, and fever?”
“No, no fever or chest pain. And I haven’t lost any weight.”
“Have you had any nausea, vomiting, or diarrhea?”
“No. None of that. I can’t think of anything else.”
Do you have shortness of breath when you are active and when you are at rest?”
“I notice it mostly when I go upstairs or walk quickly. It is worse when I go up more than two flights of stairs.”
“Have you had in the past, or currently have exposures to things that can cause cough, like chemicals, and smoking?”
“I smoked one to two packs a day for 26 years. I have cut back on my smoking. I’m down to half a pack per day. I am a farmer, and so could have shortness of breath from an irritant, chemical, or allergen. I always wear protective gear for any chemicals, dusts or other irritants. I have never had any allergic or other reactions at work or at home.”
You congratulate Mr. Barley on his efforts to cut down his smoking.
Do you have any trouble lying flat when you sleep?”
“I like sleeping on two pillows, but I don’t need to do it. It just makes my neck more comfortable.”
You learn that he has not traveled recently, which could have exposed him to an unusual form of pneumonia. He also has not been exposed to tuberculosis. From other questions, you learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). You know that he has had no orthopnea.
As a farmer, he is active during the day. Deconditioning is not likely.
Wondering if his shortness of breath is due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes. You keep asking him a series of more questions.
“Any serious illnesses in the past?”
“I’ve only been seen a couple of times for cuts and stitches recently.”
He reveals that he has never been admitted to the hospital as an adult. He had a tonsillectomy when he was 12 years old. He has had no other surgeries and is not taking any medications. He has been seen in the office for acute concerns over the past 10 years but has no chronic illness.
“I’d like to ask about your personal life. Tell me about your home life.”
“I live with my wife. We’ve been married 35 years.”
He tells you also that they have two children who are grown. He runs a farm 30 minutes away from the city. He reports no exposure to any dusts or chemicals on the job because he raises some of the crops organically and wears protective clothing as needed. He confirms about a 40 cigarette pack-year history, and notes he drinks one beer every few days.
“Tell me about your immediate family health history.”
You say, “So I understand that you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes, and have been cutting down.”
Mr. Barley is a 58-year-old male with a 40 pack/year history of smoking who presents with a two-week history of productive cough and dyspnea on exertion. He has had similar symptoms during the past two winters. He reports no fever, chest pain, epigastric pain, symptoms of CHF, recent travel, TB exposures, or chemical exposures without wearing protective equipment.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
1. Epidemiology and risk factors: 58-year-old smoker
2. Key clinical findings about the present illness using qualifying adjectives and transformative language:
· Productive cough
· Dyspnea on exertion
· Similar symptoms past two winters
· No fever, chest pain, epigastric pain, symptoms of CHF, recent travel, TB, or notable chemical exposures.
“Let’s go in and do the physical together,” says Dr. Wilson. “But, first, what are you thinking so far, in terms of a differential?”
After pausing to think, you reply to Dr. Wilson, “He could have bronchitis.”
“Good thought.” Dr. Wilson added, “What in the history supports bronchitis?”
You reply that the cough and shortness of breath of two to three weeks duration could support acute bronchitis.
Dr. Wilson tells you, “While the duration of illness provides a clinical distinction between acute and chronic bronchitis, the actual mechanisms and pathophysiology also probably differ between the two. Chronic bronchitis causes long-term inflammation that can lead to irreversible structural changes. He might qualify for this diagnosis because he describes cough with phlegm production during the past two winters. But let’s assume for the moment that he doesn’t have chronic bronchitis.”
He then prompts you, “What else are you thinking for the differential diagnosis?” Asthma, Chronic obstructive pulmonary disease (COPD), Lung cancer. Dr. Wilson says, “Why don’t you review the physical examination findings consistent with COPD while I return a phone call to a patient?”
While Dr. Wilson is gone, you go online to learn more about what physical findings you should look for in a patient with COPD.
When you are finished, you rejoin Dr. Wilson and approach the room where Mr. Barley is waiting.COPD clinical findings: Increased anteroposterior (AP) diameter of the chest, Decreased diaphragmatic excursion, Wheezing (often end-expiratory), Prolonged expiratory phase
Your exam reveals:
· Temperature is 37.2 °C (98.9 °F)
· Pulse is 94 beats/minute
· Respiratory rate is 22 breaths/minute
· Blood pressure is 128/78 mmHg
General: Appears mildly short of breath
Head, eyes, ears, nose and throat (HEENT): Normocephalic / atraumatic, conjunctivae and sclerae are normal, PERRL, oropharynx is normal.
Neck: Supple without masses, lymphadenopathy, or thyromegaly. Laryngeal height measures 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration.
Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely.
Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border (RUSB) with radiation to the left lower sternal border (LLSB).
Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness.
Extremities: 1+ pitting pretibial edema.
Dr. Wilson asks, “What test can we do to confirm that COPD is the correct diagnosis?” Pulmonary function testing
While Mr. Barley gets dressed, Dr. Wilson takes the opportunity to teach you about pulmonary function tests. He shows you a graph, and explains how spirometry is helpful in diagnosing COPD
“So let’s compare asthma to COPD,” suggests Dr. Wilson. “Why does it matter? Why worry about any differences between asthma and COPD?” You and Dr. Wilson discuss the differences in prognosis and treatment modalities for COPD versus asthma.
“Cigarette use makes either of the conditions worse, of course,” adds Dr. Wilson. “We will have to address that issue with him no matter what.”
Dr. Wilson finishes up the discussion of asthma by referring you to the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline, which clarifies that it is not always possible to differentiate between asthma and COPD, and it makes sense to treat patients who have features of both as if they had asthma.
Dr. Wilson notes, “The first step – often combined with confirming the diagnosis of COPD – is to determine the stage of severity. Different organizations use slightly different categories. Here are the GOLD criteria. All you have to remember is the FEV1 to FVC ratio is less than 0.7 for all stages of COPD, and then the cutoffs for FEV1 are 80, 50, and 30% of predicted.”
Which of the following are the best next steps in management?” Help the patient to quit or decrease smoking. and Prescribe an albuterol metered-dose inhaler on an as-needed basis.
Dr. Wilson asks you to consider how you might encourage Mr. Barley to quit smoking and offers you a clinician’s guide to the five As of counseling smokers to quit.
You and Dr. Wilson then join Mr. Barley in the room. “Mr. Barley,” begins Dr. Wilson, “from your physical exam and the symptoms you describe, it appears that you have chronic obstructive pulmonary disease, usually referred to as COPD. For us to be sure, however, we would like to test your breathing function. During this test, you’ll be asked to blow into a large tube connected to a spirometer. This machine measures how much air your lungs can hold and how fast you can blow the air out of your lungs.”
Dr. Wilson concludes, “OK, Mr. Barley. After your spirometry, we’ll talk about next steps.”
\Mr. Barley soon returns from the lab with his pulmonary function t (PFT) report.
The post-bronchodilator FEV1/FVC ratio is 69%, which is less than 70%, indicating obstructive airway disease. Since significant reversibility is defined as an increase in FEV1 ≥ 12% after bronchodilator treatment, the absence of significant change of FEV1 following bronchodilator treatment on this PFT argues against asthma. The FVC is above normal or predicted, so there is no restriction to airflow. The diagnosis is likely COPD. With the FEV1 around 100%, definitely above 80% predicted, the severity is mild. So this patient has mild COPD. The lung age is an evidence-based talking point that can be used to motivate patients to consider quitting smoking.
You and Dr. Wilson enter the exam room after the two of you agree that you will be the one to inform Mr. Barley of the results.
You begin, “Mr. Barley, the lung-function report shows that your lung function is decreased, and you do have mild COPD. This means that there’s a blockage within the tubes and air sacs that make up your lungs, which makes it harder to exhale, or blow out the air, after you breathe it in. When you can’t properly exhale or breathe out, air gets trapped in your lungs and makes it difficult for you to breathe in normally. COPD is usually caused by long-term smoking and could be prevented by not smoking or quitting smoking. However, once symptoms begin, the damage to your lungs can’t be reversed. While there is no cure, there are ways to help you breathe better. For one, we are going to prescribe a medication for you that you will inhale, so it will go directly to your airways and minimize side effects.”
Next, you and Dr. Wilson also talk with Mr. Barley about quitting smoking, using the counseling guidance outlined in the handout. You offer Mr. Barley the phone number of your medical center’s smoking cessation program, and Dr. Wilson asks in a friendly way if he can call Mr. Barley in three weeks to ask about his efforts to stop smoking, to which Mr. Barley agrees.
Dr. Wilson turns to you and says, “So far, we have introduced pharmacologic therapy to improve Mr. Barley’s current quality of life. Our next goal is to prevent a COPD exacerbation. Since infection is a common cause of COPD exacerbations, we should offer Mr. Barley immunizations that might avert certain infections.”
Which of the following are indicators that an antibiotic would be helpful for a patient with a diagnosis of an acute exacerbation of COPD?Change in sputum color Increased dyspnea Increased sputum (phlegm) production
· Discuss the Mr. Barley’s history that would be pertinent to his respiratory problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
· Describe the physical exam and diagnostic tools to be used for Mr. Barley. Are there any additional you would have liked to be included that were not?
· What plan of care will Mr. Barley be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
please use apa references