Common Obstructive Diseases

Patients with obstructive lung disorders have difficulty getting air out of their lungs due to increased resistance in the airways and therefore patients with obstructive lung disease are commonly associated with decreased expiratory flow rates. Spirometry is a common pulmonary function test used to diagnose airflow obstruction in patients with symptoms of obstructive lung disorders. The three primary spirometry tests for patients with obstructive lung disease are FVC, FEV1, and FEV1/FVC ratio. If you recall FVC (forced vital capacity) is the maximum amount of air that a person can expel from the lungs after a maximum inspiration. FEV1 (forced expiratory volume in one second) is the volume of air expelled in the first second of forced expiration, FVC). FEV1/FV ratio is expressed as a percentage and is calculated by taking the FEV1 divided by the FVC and multiplied by 100. The FEV1/FVC ratio or FEV1/FVC% is the primary variable used to determine the presence of airflow limitation.

The presence of obstruction is confirmed when both the FEV1 and FEV1/FVC ratio are decreased.

RT’s are responsible for obtaining clinical data especially when a patient is experiencing an exacerbation. This is important for determining the problem(s) and the best course of action. Another major component of the respiratory therapy profession is clinical problem-solving. We are expected to gather information and make an informed decision based on the information we gather. Read the following case study before proceeding to the assignment where you will utilize the SOAP method in assessing the patient below.

You will use the knowledge and skills you’ve learned thus far to work through the clinical problem below:

History

A 62-year-old man has a long history of cough and shortness of breath, coupled with multiple hospitalizations. He was admitted because of severe, worsening dyspnea. He lived and worked in Pittsburgh, Pennsylvania, for 35 years as a foundry worker in a steel manufacturing plant. His wife died 10 years prior to this report. After his wife’s death, he lived alone for 9 years and managed his daily activities with progressive difficulty.

Approximately 2 years before this admission, he was forced to retire early because of declining health. His doctor told him that he had the chronic obstructive pulmonary disease (COPD). For the past year, he has been living with his brother’s family in Chicago, Illinois. The patient’s brother indicated during the interview that the patient might “have the flu again.”

The patient had a 35-pack/year history of smoking unfiltered cigarettes, but he stopped smoking at the time of his forced retirement. His last hospitalization was 9 weeks before this admission. At that time, he was hospitalized for 2 days for cough, muscle aches and pains, fever, and respiratory distress. He underwent a complete pulmonary function study and received bronchopulmonary hygiene therapy, oxygen therapy, and instruction in at-home breathing exercises.

Also at this time, hospital personnel noted that the patient’s expiratory flow rate measurements had declined significantly since his pulmonary function tests (PFTs) a year earlier. In fact, in the past year his forced expiratory volume in 1 second (FEV1) had declined from 70% of that predicted to 45% of that predicted. At discharge 9 weeks before this admission and on 1.5 L of oxygen per minute by nasal cannula, the patient’s arterial blood gas (ABG) values were as follows: pH 7.37, Paco2 67 mm Hg, HCO3- 36 mEq/L, and Pao2 63 mm Hg. He had received an influenza vaccine 6 months earlier and pneumococcal vaccine 2 years earlier.

At the time of discharge 9 weeks earlier, he had demonstrated pursed-lip breathing and was using his accessory muscles of inspiration at rest. He had demonstrated no spontaneous cough or sputum production. His bronchodilator therapy had been discontinued 1 year ago because it had been “found to be ineffective” during his PFT. He had been strongly encouraged to perform his pulmonary rehabilitation exercises daily. A weekly exercise diary was given to him by the respiratory care department at discharge.

Physical Examination

In the emergency room, the patient was febrile, cyanotic, and in obvious respiratory distress. He appeared malnourished. He was 180 cm (6 feet tall) and weighed 66 kg (146 lb). His skin was cool and clammy. The patient said, “I’m so short of breath!”

His vital signs were as follows: blood pressure 155/110, heart rate 95 bpm, respiratory rate 25/min, and oral temperature 38.3° C (101° F). He was using his accessory muscles of inspiration and breathing through pursed lips. An increased anteroposterior diameter of the chest was easily visible. Percussion revealed that he had low-lying, poorly mobile hemidiaphragm. Expiration was prolonged, and his breath sounds were diminished. No wheezes were noted, but crackles could be heard over the right lower lobe.

A chest x-ray film showed pulmonary hyperinflation, severe apical pleural scarring, a large bulla in the right middle lobe, and a right lower lobe infiltrate consistent with pneumonia (Figure 1). On instruction the patient’s forced cough was weak and productive of a small amount of yellow sputum. On 1.5 L of oxygen per minute by nasal cannula, his ABGs were as follows: pH 7.59, Paco2 40 mm Hg, HCO3- 37 mEq/L, and Pao2 38 mm Hg. The physician ordered a pulmonary consultation and stated that she did not want to commit the patient to a ventilator if possible. The patient also was started on intravenous doses of aminophylline and methylprednisolone.

Prompt
Be sure to review the document on S. O. A. P ChartingPreview the document

Based on the clinical data presented above construct a SOAP for this patient.
Submit your answers in at least 500 words on a Word document. You must cite at least three references in the IWG format to defend and support your position.