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NR601 Primary Care of the Maturing and Aged Family

Week 2 Discussion

COPD Case Study Part 1

Purpose

Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice.  The purpose of this activity is to develop students’ clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group.

Activity Learning Outcomes

Through this discussion, the student will demonstrate the ability to:

Demonstrate competence in the evaluation and management of common respiratory problems (WO 2.1) ?(CO,2,3,4,5)

Distinguish between obstructive and restrictive lung disease (CO 2, 4) Develop a management plan for the case study patient based on identified primary, secondary and differential diagnoses.?(WO 2.2) (CO 2,4) 

Interpret pulmonary function test results. (WO 2.3) (CO 2, 4)

Case Study – Part 1

Date of visit: November 20,2019

A 62 year-old Caucasian male presents to the office with persistent cough and recent onset of shortness of breath. Upon further questioning you discover the following subjective information regarding the chief complaint.

History of Present Illness 

Onset 

6 months 

Location 

Chest 

Duration 

Cough is intermittent but frequent, worse in the AM 

Characteristics 

Productive; whitish-yellow phlegm 

Aggravating factors 

Activity 

Relieving factors 

Rest 

Treatments 

Tried Robitussin DM without relief of symptoms 

Severity 

Unable to walk > 20ft without stopping to catch his breath. Last year at this time he routinely walked 1 mile per day without difficulty 

Review of Systems (ROS) 

Constitutional 

Denies fever, chills, or weight loss? 

Ears 

Denies otalgia and otorrhea 

Nose 

Denies rhinorrhea, nasal congestion, sneezing or post nasal drip.  

Throat 

Denies ST and redness 

Neck 

Denies lymph node tenderness or swelling 

Chest 

Describes a persistent productive cough upon wakening for the last 6 months. Color of phlegm is usually white-yellowish. Shortness of breath with activity. 

Cardiovascular 

Denies chest pain and lower extremity edema 

 

 

History 

Medications 

Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamin daily 

PMH 

Primary hypertension 

PSH 

Cholecystectomy, appendectomy 

Allergies 

Penicillin (hives) 

Social 

Married, 3 children 

Senior accountant at a risk management firm 

Habits 

Former smoker (20 pack-year), quit “cold turkey” when father died; Denies alcohol or illicit drug use. 

FH 

Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker) 

Mother is alive (osteoporosis)  

Healthy siblings 

 

 

Physical exam reveals the following:

Physical Exam 

Constitutional 

Adult male in NAD, alert and oriented, able to speak in full sentences  

VS 

Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA 

Head 

Normocephalic 

Ears 

Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. 

Nose 

Nares patent. Nasal turbinates clear without redness or edema. Nasal drainage is clear. 

Throat 

Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. 

Neck 

Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. No JVD 

Cardiopulmonary 

Heart S1 and S2 with no murmurs, noted. Lungs clear to auscultation bilaterally with faint forced expiratory wheezes in bilateral bases. Respirations unlabored. Legs without edema. 

Abdomen 

Soft, non-tender. No organomegaly 

Requirements/Questions:

Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. May use approved medical abbreviations. Avoid redundancy and irrelevant information.

Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement (2-3 sentences) of pathophysiology for each.

Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.

Rank the differential in order of most likely to least likely.

Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based practice (EBP) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBP evidence.

DISCUSSION CONTENT 

Category 

Points 

% 

Description 

Application of Course Knowledge 

15 

30% 

  1. A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND 
  2. Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND 
  3. A brief statement of pathophysiology is included for each diagnosis; AND 
  4. Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND 
  5. The differential is ranked in order from most likely to least likely; AND 
  6. Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND 
  7. Testing decisions are well supported with EBP arguments that are in-line with the clinical scenario and appropriate for the primary care setting 

(7 critical elements) 

Support from Evidence-Based Practice (EBP) 

15 

30% 

  1. Discussion post is supported with appropriate, scholarly sources; AND  
  2. Sources are published within the last 5 years (unless it is the most current CPG); AND 
  3. Reference list is provided and in-text citations match; AND 
  4. All testing decisions are fully supported with an appropriate EBP argument 

(4 critical elements) 

Interactive Dialogue 

10 

20% 

  1. Student provides a substantive* response to at least one topic-related post of a peer; AND 
  2. Evidence from appropriate scholarly sources are included; AND 
  3. Reference list is provided and in-text citations match; AND 
  4. Student responds to all direct faculty questions 

 (*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response 

(4 critical elements) 

 

 

 

Total CONTENT Points= 40 pts

 

 

DISCUSSION FORMAT 

Category 

Points 

% 

Description 

Organization 

5 

10% 

  1. Case study response is presented in a logical format, AND 
  2. Responses are in sequence with the numbered questions AND
  3. The case study response is understandable and easy to follow AND 
  4. All responses are relevant to the case topic 

(4 critical elements) 

Grammar, Syntax, Spelling & Punctuation 

5 

10% 

Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors* 

 

 

 

 

Total FORMAT Points= 10 pts 

 

 

 

DISCUSSION TOTAL= 50 pts 

 

DQ2 COPD Case Study Part 2

Purpose

Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice.  The purpose of this activity is to develop students’ clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group.

Activity Learning Outcomes

Through this discussion, the student will demonstrate the ability to:

Demonstrate competence in the evaluation and management of common respiratory problems (WO 2.1) (CO 2,3,4,5)

Distinguish between obstructive and restrictive lung disease (CO 2, 4) Develop a management plan for the case study patient based on identified primary, secondary and differential diagnoses.?(WO 2.2) (CO 2,4) 

Interpret pulmonary function test results. (WO 2.3) (CO 2, 4)

Case Study – Part 2

You ordered a CXR and spirometry at the previous visit and he returns today to review the results. Physical exam and symptoms are unchanged since last visit. Vital signs at this visit are: Temp-98.3, P-68, RR-20, BP 152/90, Height 68.9in., Weight 258 pounds, O2sat 94% on RA

CXR Result:

No acute infiltrates or consolidations are seen. Cardiac and mediastinal silhouettes are normal. No hilar enlargement is evident. Osseous thorax is intact.

Spirometry Results:

Pre-Bronchodilator 

Post-Bronchodilator 

 

Predicted 

Actual 

%Predicted 

Actual 

% Predicted 

% Change 

FVC (L) 

4.52 

3.01 

67 

3.08 

68 

FEV1 (L) 

3.40 

1.58 

46 

1.60 

47 

FEV1/FV  

.75 

.52 

— 

.52 

— 

 

Requirements/Questions:

What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)

Identify the corresponding ICD-10 code.

Provide a treatment plan for this patient’s primary diagnosis which includes:

Medication*

Any additional testing necessary for this particular diagnosis*

Patient education

Referral

Follow up

 Provide an active problem list for this patient based on the information given in the case.

 Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBP argument for each treatment or testing decision.

*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based practice  (EBP) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.

Over-the-counter (OTC) and RXs must be written in full as if handing a prescription to the patient in the office.??

Example:??

Amoxicillin 500 mg capsule?

1 tab po BID q 10 days?

Disp #20 no refills??

DISCUSSION CONTENT 

Category 

Points 

% 

Description 

Application of Course Knowledge 

15 

30% 

  1. Student chooses one appropriate diagnosis for the patient; AND 
  2. Diagnosis is supported with strong pertinent positive and negative subjective and objective data from parts 1 & 2; AND 
  3. The ICD code for the diagnosis is correct; AND 
  4. Treatment plan for primary diagnosis includes medication, additional testing, patient education, and referral; AND 
  5. Prescription and OTC medications are written appropriately as a RX and all components are correct; AND 
  6. Treatment decisions (medication, additional testing, referrals) are supported with appropriate EBP arguments; AND  
  7. An accurate problem list is presented based on case information; AND  
  8. Student discusses changes (or not) to the overall treatment plan for the patient for pertinent issues; AND  
  9. An appropriate F/U plan is provided 

(9 critical elements) 

Support from Evidence-Based Practice (EBP) 

15 

30% 

  1. Discussion post is supported with appropriate, scholarly sources AND 
  2. Sources are published within the last 5 years (unless the most current CPG is used) AND 
  3. A reference list is provided with in-text citations that match AND 
  4. All testing decisions are fully supported with an appropriate EBP argument 

(4 critical elements) 

Interactive Dialogue 

10 

20% 

  1. Student provides a substantive* response to at least one topic-related post of a peer AND 
  2. Includes evidence from appropriate scholarly sources AND 
  3. Provides a reference list which match in-text citations AND 
  4. Student responds to all direct faculty questions 

(4 critical elements) 

 

 

 

Total CONTENT Points= 40 pts 

DISCUSSION FORMAT 

Category 

Points 

% 

Description 

Organization 

5 

10% 

  1. Case study response is presented in a logical format, AND 
  2. Responses are in sequence with the numbered questions AND 
  3. The case study response is understandable and easy to follow AND 
  4. All responses are relevant to the case topic 

(4 critical elements) 

Grammar, Syntax, Spelling & Punctuation 

5 

10% 

Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors* 

 

 

 

 

Total FORMAT Points= 10 pts 

 

 

 

DISCUSSION TOTAL= 50 pts 

 

  
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