NU636 Unit 3: Discussion Treatment of COPD

Initial Response

Scenario: You are seeing an 89-year-old male who has a history of smoking 2 packs of cigarettes a day for 69 years.

• He quit smoking cold turkey when he was 78 years old.
• He is in your office for a general health evaluation.  He reports ongoing challenges with ‘belching’ but other than that he conveys that he is feeling pretty good.
• He is on no routine medications.
• During your interview with the patient you note that he utilizes pursed lip breathing.  At times you note a faint ‘whistling’ sound associated with his respiratory effort.
•  In conducting your review of systems he reports a cough, particularly in the mornings, productive for thick clear to white sputum.
• When queried about shortness of breath he does indicate that he gets SOB more easily than he used to.
• His breath sounds are course and diminished in the lower lobes bilaterally.

Please develop a discussion that responds to each of the following prompts.  Where appropriate your discussion needs to be supported by scholarly resources.  Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.

Initial Post

Utilize the information provided in the scenario to create your discussion post.

Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).

Structure your ‘P’ in the following format:  [NOTE:  if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]

Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]

Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit

Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making

Support the interventions outlined in your ‘P’ with scholarly resources.

Please be sure to validate your opinions and ideas with citations and references in APA format.

Solution: U636 Unit 3: Discussion Treatment of COPD

Subjective:

Chief Complaint: Patient reports ongoing challenges with belching and feels pretty good otherwise.

HPI: 89-year-old male with history of smoking 2 packs of cigarettes a day for 69 years. Patient reports quitting smoking at the age of 78 years old. Patient wants to be seen for general health check-up.

ROS: Patient reports a cough, often occurring in the morning that is productive with clear to white sputum. Patient notes that he gets SOB more easily than he used to.

Current Medications, Allergies: No current routine medications

Objective:

Respiratory: Patient utilizes pursed lip breathing. Faint whistling sound associated with respiratory effort. Breath sounds are coarse and diminished in the lower lobes bilaterally.

Assessment:

This patient is showing symptoms consistent with chronic obstructive pulmonary disease. His smoking habit dates back 69 years, when he smoked two packs a day. In COPD, symptoms include shortness of breath, a persistent cough, and the production of pepsin (MacLeod et al., 2021). The patient is at increased risk of COPD due to their long smoking history. When diagnosing COPD, spirometry is the main standard. One way to measure lung function is by spirometry, which measures the rate and force of exhalation. Peak expiratory flow and arterial blood gas are two more tests that can be ordered to assess lung function. Arterial blood gas analyzes the blood for oxygen and carbon dioxide levels (MacLeod et al., 2021).

Plan:

Therapeutic:

Reminding the patient that they have successfully quit smoking eleven years ago is the first and most important step (MacLeod et al., 2021). Individualized medication treatment plans should take into account each patient’s unique set of symptoms, medical history, risk of worsening symptoms, desired level of device variability, and other relevant factors (Vogelmeier et al.,…Please click purchase button below to get full answer for $5

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