The following case study is provided in a SOAP format – it is a way to gather all the data from lab, radiology, interview, and physical assessment to provide a logical framework to focus on the patient’s problem and come up with suggested treatment plan.
SOAP stands for: subjective data; what the patient tells you (how they perceive their chief complaint). Objective data is anything we can see, feel or measure. Assessment in this regard means putting all the data together to suggest what is wrong and plan is the treatment based on our assessment.
A patient with a long standing history of COPD with a 60 pack/year smoking history is admitted to the ER with worsening of his pulmonary condition. He complains of increasing shortness of breath x 3 days and a congested non-productive cough. The patient has been treated for sleep apnea at home with a CPAP machine but is not compliant with the therapy.
Subjective: Increasing dyspnea, congestion
Objective: Patient is using accessory muscle of respiration and has a prolonged expiration time. Upon inspection the patient’s chest has an increased A-P diameter. Jugular veins distended and skin is moist and clammy. Pulse is irregular and rapid, lips and nails show cyanosis, the patient is purse lip breathing. Pitting edema of the ankles is noted.
Further examination reveals the following:
• Chest auscultation reveals decreased air entry in the bases with course expiratory crackles noted.
• Heart sounds show an exaggerated P2
• Chest percussion – bilateral hyper-resonance
• CXR – hyper inflated lungs and flattened diaphragms with consolidation noted in the right lower and middle lobes
• Vital signs: Temperature 37.4 C. f = 14 with prolonged exhalation time, HR 88, BP 148/88, Pulse oximetry 76% on room air
• Labs: Hemoglobin 20 g/dl, Hematocrit 60%, white blood cell count 22,000, with neutrophils and monocytes elevated. Electrolytes normal
• Sensorium – the patient is alert and anxious
Assessment: Exacerbation of COPD (emphysema) with cor pulmonale and possible pneumonia
Plan: Start oxygen therapy and titrate to a pulse oximetry reading of 88 – 90%, get culture and sensitivity of sputum to identify infective microorganism in pulmonary system for antibiotics, suggest a diuretic such as Lasix or Bumex for the pitting edema and consider pulmonary hygiene to help patient expectorate secretions. Follow up with ABG one hour after starting oxygen (they may also get the ABG immediately before oxygen).
In your own words, provide detailed responses to the following questions:
Provide detailed responses to the following questions:
Why does this patient with COPD have a prolonged exhalation time?
Define the term cyanosis and indicate specifically what tells you about the patient’s medical status.
What is the common term used for an increased A-P diameter of the chest and how is it caused?
What is “pursed lip breathing” Why is the patient doing it? How is it helping the patient?
In this patient, what is causing pitting edema of the ankles?
Explain why, while evaluating the breath sounds, you would not hear the air well in the bases of an emphysema patient with an increased A-P diameter.