ANP-635-History and Physical Respiratory Failure Essay

ANP-635-History and Physical Respiratory Failure Essay

History and Physical Note

Chief Complaint or Reason for Consult: “Shortness of breath.”

History of Present Illness (HPI): M.K. is a 79-year-old AA female who presented with a complaint of shortness of breath. The SOB began about four days ago when she started feeling a need to catch her breath, and this worsened when she was walking or doing her normal house chores. The patient also reported an increased breathing rate, and her body was unusually hot. However, the dyspnea with exertion rapidly progressed to severe dyspnea at rest, accompanied by a high respiratory rate. On arrival at the ED, the patient was anxious and agitated. She was immediately administered a high concentration of inspired oxygen.

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Past Medical History: History of COPD, diagnosed at 63 years. Admitted thrice in the past two years due to pneumonia.

Past Surgical History: Appendectomy at 43 years.

Family History: The mother had heart failure and died from a heart attack at 89. The father died from pancreatic cancer at 86 years. The elder sister died from a heart attack at 78 years.

Social History: M.K. is a retired Travels consultant. She lives with her husband in their farmhouse in Kerrville, TX. They have three children, 55, 53, and 46 years old. She has had a smoking history since she was 22 years old and stopped at 64 years following a COPD diagnosis. She smoked 2 PPD before her being advised to quit. She admits to taking 3-4 glasses of whiskey on weekends. Her source of income includes her pension and interests from various investments. She has no advanced directives.

Allergies: No food/drug allergies.

Home Medications: Ipratropium inhaler 2 actuation every 6 hours; Salmeterol 1 inhalation BD; Vitamin D/Calcium supplements.

Hospital Medications: Low-molecular-weight heparin, IV Hydrocortisone 200 mg OD.

Review of Systems:

• CONSTITUTIONAL: Positive for fever, activity intolerance, and increased fatigue
• EYES: Denies eye pain, excessive tearing, or blurry vision.
• EARS, NOSE, and THROAT: No ear pain, ear discharge, hearing loss, nasal discharge, sneezing, or sore throat.
• CARDIOVASCULAR: Positive for dyspnea on exertion and at rest. Denies palpitations, chest discomfort, or edema.
• RESPIRATORY: Reports increased breathing rate. Denies cough, sputum, or wheezing.
• GASTROINTESTINAL: Denies nausea, vomiting, abdominal pain, bowel changes, or tarry stools.
• GENITOURINARY: Denies dysuria, blood in urine, abnormal PV discharge, or pelvic pain.
• MUSCULOSKELETAL: Denies joint pain or stiffness, back pain, or muscle pain
• INTEGUMENTARY: Denies skin rashes, discoloration, bruises, or lesions.
• NEUROLOGICAL: No headaches, dizziness, muscle weakness, loss of consciousness, or tingling sensations.
• PSYCHIATRIC: Reports occasional sleep disturbance with nighttime awakening. Denies anxiety or mood symptoms.
• ENDOCRINE: Denies increased urination, excessive hunger, acute thirst, or heat/cold intolerance.
• HEMATOLOGIC/LYMPHATIC: Denies easy bruising, bleeding, or swollen lymph nodes.
• ALLERGIC/IMMUNOLOGIC: Denies rashes, hives, or any allergic reactions.

Physical Exam:

• GENERAL APPEARANCE: AA female patient in her late 70s. She is well-nourished and in acute respiratory distress. She is alert and oriented.
• VITAL SIGNS: BP- 110/70; HR-128;RR-26; Temp- 100.7; SPO2- 88; HT; 5’2; WT- 132; BMI- 24.1
• HEENT: Normocephalic and atraumatic. Eyes: Sclera is white; Conjunctiva is pink; PERRLA. Ears: Tympanic membranes are patent, transparent, and shiny. Nose: No rhinorrhea or epistaxis. Patent nostrils and nasal septum; Mouth: Pink and moist mucous membranes; Tongue is mid-line, pink, and non-inflamed; One tooth cavity. Throat: Tonsillar glands are non-erythematous.
• NECK: Full ROM; Trachea is mid-line; Thyroid gland is normal.
• CHEST: Asymmetrical chest expansion. Labored breathing with the use of accessory muscles.
• LUNGS: Faint heart sounds. Dullness to percussion. Rales present. No wheezing or rhonchi.
• HEART: Heart rate- 128 b/min. No edema or jugular veins distension; S1 and S2 normal on auscultation. No gallop sounds, bruits, or systole was heard.
• BREASTS: Symmetrical; No skin color changes, nipple discharge, breast tenderness, masses, or lumps.
• ABDOMEN: Round with normal pigmentation and moves up and down on respiration. No bruits; BS normoactive on all quadrants. No hepatomegaly or splenomegaly on percussion. No tenderness, masses, guarding, or organomegaly.
• GENITOURINARY: [Female]. Normal external genitalia No pelvic tenderness. Normal urethral meatus is normal.
• RECTAL: Normal sphincter tone. No masses or tenderness.
• EXTREMITIES: Cyanosis present in fingers.
• NEUROLOGIC: The patient is restless, anxious, and confused.
• PSYCHIATRIC: Alert and oriented x4. Affect is appropriate. Coherent speech and thought process. No delusions, hallucinations, obsessions, homicidal, or suicidal thoughts were noted.
• SKIN: Dark, warm, and well-perfused skin with good turgor. Bluish discoloration in the extremities.
• LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

• ABG: PaO2-54 mmHg; PaCO2-38 mmHg
• WBC- 12,500 µL
• FEV1 -to-FVC ratio- decreased

Differential Diagnosis:

Respiratory Failure with SIRS: Type 1 respiratory failure is characterized by a partial pressure of oxygen (PaO2) < 60 mmHg and a normal or decreased partial pressure of carbon dioxide (PaCO2). Patients present with respiratory symptoms like dyspnea, cough, sputum production, chest pain, hemoptysis, and wheezing. Symptoms from other organ systems like fever, decreased appetite, heartburn, and significant weight loss are also present. The diagnostic criteria for Systemic Inflammatory Response Syndrome include at least two of the following criteria: fever >38.0°C or hypothermia <36.0°C, tachypnea >20 breaths/minute, tachycardia >90 beats/minute or leucocytosis >12,000/µL (Rababa et al., 2022). The patient has a reduced PaO2 of 54 mmHg with a PaCO2 within a normal range, which indicates respiratory failure. She also has respiratory symptoms and has met the criteria for SIRS with tachycardia, tachypnea, fever, and elevated WBC count of 12,500 µL.

Acute respiratory distress syndrome (ARDS): ARDS is non-cardiogenic pulmonary edema presenting rapidly progressive dyspnea, tachypnea, and hypoxemia. Other clinical manifestations include pleuritic chest pain, sputum production, fever, and rales (Kaku et al., 2020). This is a differential diagnosis based on the patient’s positive symptoms of dyspnea, tachypnea, fever, rales, and a low PaO2, indicating hypoxemia.

Community-Acquired Pneumonia (CAP): The characteristic pulmonary physical exam findings include: Tachypnea, rales over the affected lobe, increased tactile fremitus, bronchial breath sounds, and dullness on chest percussion (Rider & Frazee, 2018). The patent presents with pulmonary symptoms characteristic of CAP, including tachypnea, rales, and dullness on percussion. She also has a fever, reduced saturation levels, and elevated WBC, which occur in CAP.

Treatment Plan: Treatment will aim to correct hypoxemia since it is a threat to organ function.

Medications: Low-molecular-weight heparin

IV Hydrocortisone 200 mg OD

Salmeterol 1 inhalation BD

Non-pharmacologic: Oxygen supplementation via nasal cannula to correct hypoxemia (Summers et al., 2022).

Health Education: Adherence to pharmacological therapy. Pulmonary rehabilitation interventions for COPD.

Consultations: Consult a Pulmonary specialist if the respiratory failure does not improve with treatment.

Follow-up: The patient will be scheduled for a follow-up two weeks after discharge.

Geriatric or Ethical Considerations:

Geriatric patients are predisposed to Respiratory failure. The clinician should consider the factors that trigger Respiratory failure in geriatrics, like acute exacerbations of COPD, acute heart decompensation, severe community-acquired pneumonia, and pulmonary embolism. The patient, in this case, has COPD, which is the likely cause of respiratory failure. Foccillo (2019) explains that in the management of respiratory failure in geriatrics, it is mandatory to reverse and prevent tissue hypoxia through conventional oxygen therapy or invasive or non-invasive mechanical ventilation. Ethical considerations surround the principles of beneficence and nonmaleficence. The clinician should uphold the two ethical principles by implementing interventions that will promote the best treatment outcomes and cause no harm to the patient. Thus, interventions should be guided by evidence-based research. In addition, the clinician should obtain consent from the patient and respect her treatment decisions.

References

Foccillo, G. (2019). The Infections Causing Acute Respiratory Failure in Elderly Patients. Ventilatory Support and Oxygen Therapy in Elder, Palliative and End-of-Life Care Patients, pp. 35–45. https://doi.org/10.1007/978-3-030-26664-6_5

Kaku, S., Nguyen, C. D., Htet, N. N., Tutera, D., Barr, J., Paintal, H. S., & Kuschner, W. G. (2020). Acute respiratory distress syndrome: etiology, pathogenesis, and summary on management. Journal of Intensive Care Medicine, 35(8), 723-737. https://doi.org/10.1177/08850666198550

Rababa, M., Bani Hamad, D., & Hayajneh, A. A. (2022). Sepsis assessment and management in critically Ill adults: A systematic review. PloS one, 17(7), e0270711. https://doi.org/10.1371/journal.pone.0270711

Rider, A. C., & Frazee, B. W. (2018). Community-Acquired Pneumonia. Emergency medicine clinics of North America, 36(4), 665–683. https://doi.org/10.1016/j.emc.2018.07.001

Summers, C., Todd, R. S., Vercruysse, G. A., & Moore, F. A. (2022). Acute Respiratory Failure. Perioperative Medicine, 576–586. https://doi.org/10.1016/B978-0-323-56724-4.00039-3

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Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:

History and Physical Note

1. Chief complaint/reason for admission/visit/consult.
2. HPI for the H&P or consult notes.
3. Medical, surgical, family, social, and allergy history.
4. Home medications, including dosages, route, frequency, and current medications, if a consultation note.
5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
6. Vital signs and weight.
7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
8. Lab/Imaging/Diagnostic test results (including date).

Assessment and Clinical Impressions

1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
2. Include a complete list of all diagnoses that are both acute and chronic.
3. List the differential diagnoses and chronic conditions in order of priority.

Plan Component Management and Plan Criteria Incorporation

1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
2. Discuss disposition and expected outcomes.
3. Identify and address health education, health promotion, and disease prevention.
4. Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.

General Requirements

This assignment uses a template. Please refer to the “History and Physical Note Template,” located on the college page of the Student Success Center under the AGACNP tab.

Incorporate at least three peer-reviewed articles in the assessment or plan.