NR 507 Advanced Pathophysiology; Discussion / Tammy is a 33-year-old who presents for evaluation of a cough) 2024

NR 507 Advanced Pathophysiology; Discussion / Tammy is a 33-year-old who presents for evaluation of a cough) 2024. Tammy is a 33-year-old who presents for evaluation of a cough. She reports that about 3 weeks ago she developed a “really bad cold” with rhinorrhea. The cold seemed to go away but then she developed a profound, deep, mucus-producing cough. Now, there is no rhinorrhea or rhinitis—the primary problem is the cough. She develops these coughing fits that are prolonged, very deep, and productive of a lot of green sputum. She hasn’t had any fever but does have a scratchy throat. Tammy has tried over-the-counter cough medicines but has not had much relief. The cough keeps her awake at night and sometimes gets so bad that she gags and dry heaves. Write a differential of at least five (5) possible diagnosis’s and explain how each may be a possible answer to the clinical presentation above. Remember, to list the differential in the order of most likely to less likely. Based upon what you have at the top of the differential how would you treat this patient? Suppose now, the patient has a fever of 100.4 and complains of foul smelling mucous and breath. Indeed, she complains of producing cups of mucous some days. She has some trouble breathing on moderate exertion but this is only a minor complaint to her. How does this change your differential and why? Topic responses  Discussion  Expand All More Sort By: Sarah Drum Week 2 DB 2 Bronchitis Bronchitis is an inflammation of the lower respiratory track of the bronchial tubes “Acute bronchitis is usually caused by a respiratory virus and occasionally by bacterial infection, although this occurs in less than 10 percent of cases” (Acute Bronchitis, 2016). The symptoms of bronchitis include coughing up mucus that is yellow or green, a runny or congested nose that started a few days before the chest congestion, fatigue, wheezing, shortness of breath with activities, and “coughing fits.” The patient reports having a runny nose about three weeks ago when this started. A runny nose was her only complaint when the illness started. Once the runny nose went away, the cough and chest congestion started. She currently does not have a fever, but her throat is scratchy. Her throat could be scratchy from all of the coughing she has done. Her symptoms seem to fit all of the symptoms associated with bronchitis, especially since she is not running a fever and the fact bronchitis can last several weeks. The patient is not having any fever or chills, so this could indicate that it is viral, and there is no infection. Pneumonia Pneumonia is a lung infection that can have mild to severe symptoms. They symptoms range from a cough which can produce yellow, green, or bloody mucus, fever, shortness of breath, chills, headache, fatigue, loss of appetite, and sweating. Bronchitis and Pneumonia are very similar, that is why sometimes a person is diagnosed with one when they really have the other. An x-ray can rule out or confirm pneumonia. It can begin with a sore throat, dry cough, muscle aches, and then it will progress to having a productive cough with discolored sputum. It can be from bacteria, viral, or even fungal. The patient is at more of a risk for pneumonia because she did have a cold, it could have possibly turned into a pneumonia due to the congestion (Pneumonia, 2016). Acute Sinusitis “Sinuses are hollow spaces in the bones around the nose that connect to the nose through small, narrow channels” (Sinusitis, 2016). Acute sinusitis is an infection of the sinuses. It affects one in eight adults every year. What happens is the sinus cavities become inflamed and then are unable to empty mucus. The inflammation could have come from the cold, and now that the sinus cavities are blocked from inflammation, she has developed a sinus infection. Symptoms include congestion (chest or nose), pain, pressure, or fullness in the face, and yellow or green mucus. Bacterial sinusitis is suspected if it has been longer than 10 days, and the patient is not better. The patient has had symptoms for at least three weeks, and so acute bacterial sinusitis should be suspected (Sinusitis, 2016). Asthma Even though asthma does not explain all of her symptoms, it is a possibility. The patient may have asthma and an irritant is exacerbating it, which is causing the sputum. These irritants could be pollen, smoke, or house hold chemicals. It also could explain the coughing fits she has at night, and the shortness of breath with exertion. Symptoms of asthma include tightness in the chest, wheezing, coughing (sometimes with sputum). Sometimes the patient will experience coughing fits, and may occur especially in the morning and at night. She has coughing fits at night. She could have had a case of allergic rhinitis, and not the cold. The allergic rhinitis may have triggered an asthma flare up. The patient would need to find out what is triggering it, and avoid it. Allergic Rhinitis Allergic rhinitis is an inflammation of the nasal membranes such as the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx that is caused by allergies. The symptoms vary but are sneezing, congestion (chest or nose), headache, red eyes, fatigue, and itchy nose, ear or eyes. Histamine, tryptase, chymase, kinins, and heparin are released in the blood when exposed to an allergen. The release of these into the blood stream gives the patient symptoms that cause inflammation. Once you take the allergen away, the allergic rhinitis goes away. Allergic rhinitis affectes roughly 40 million people in the United States. (Sheikh, J., MD, & Kaliner, M., MD., 2015). She may be allergic to pollen, certain chemicals she has been using lately, or other things such as mold. Based upon what you have at the top of the differential how would you treat this patient? First, I would get a chest x-ray to ensure it is bronchitis and not pneumonia. Then I would prescribe a coughing medication such as Promethazine DM that helps the patient not cough as much, but helps to thin the mucus and get it up when they do cough. This would help with her coughing fits. We want her to cough and get the mucus up, but we do not want her to dry heave and gag due to coughing. I would also give a steroid injection such as Kenalog to help dry her secretions up. The patient can then take over the counter NSAIDS such as Ibuprofen and Tylenol, as well as rest and a lot of fluids. The fluids would also help to thin the mucus, which would make it easier to cough up. Suppose now, the patient has a fever of 100.4 and complains of foul smelling mucous and breath. Indeed, she complains of producing cups of mucous some days. She has some trouble breathing on moderate exertion but this is only a minor complaint to her. How does this change your differential and why? “If it (the cold) hangs around for more than 10 days, or gets worse after it starts to get better, there’s a good chance you have sinusitis” (Sinusitis, 2016). I would then treat the patient for Sinusitis because her sinus cavities have had mucus built up for days and bacteria may be starting to grow; especially since she has a fever now. One of the symptoms of acute sinusitis is foul smelling breath and mucus, along with fever. (Sinusitis, 2016). Acute Bronchitis, Symptoms, Causes, and Risk Factors. (2016). American lung association. Asthma Symptoms, Causes, and Risk factors. (2016). American lung association. Pneumonia. (2016). American lung association. Sheikh, J., MD, & Kaliner, M., MD. (2015). Allergic Rhinitis. Sinusitis. (2016). American academy of otolaryngology-head and neck surgery. Show Less Janet Farrellyreply to Sarah Drum 9/7/2016 11:27:31 PM RE: Week 2 DB 2 Sarah, Smoking and Tammy's condition: This is a very well written answer as it is easy to follow and it contains a great deal of information! After I introduced myself to Tammy though, I would ask her if she smoked. I am one of six children and only one of my siblings smoke and even though she is not the oldest of us, she looks as though she is. Sometimes my other siblings will say, "Oh, I can't believe that she still smokes", but they don't understand the addictions of smoking and just by telling someone to stop, this isn't going to work! A couple of years ago, I did a report on smoking for a previous class and I was absolutely dumbfounded on the amount of taxes on one pack of cigarettes alone. In the state of New Jersey, for example, the tax on one pack of cigarettes is $2.70 cents, while in the state of NY, the tax, for one pack is over $4.00 dollars! While the "politicians" decided to get together and raise prices on cigarettes, to dissuade individuals from smoking, this is not the solution. If a person wants to smoke, they are going to pay any amount for a pack of cigarettes. The solution is education and, as future nurse practitioners we are here to provide those services! I would teach Tammy, if she did smoke, that there is help out there to stop smoking and she doesn't have to do it alone! For example, if Tammy lived in New Jersey, I would refer her to the New Jersey Quit line at 1-866-NJSTOPS! Reference: Campaign for Tobacco Free Kids. (2016). Map of state cigarette tax rates. Show Less Jamie Millerreply to Sarah Drum 9/11/2016 8:27:49 PM RE: Week 2 DB 2 Hello, Sarah. Good post. For this scenario, I had a difficult time trying to decide if Tammy's primary diagnosis was bronchitis or pneumonia. I ultimately choose pneumonia, and it seems I am in the minority. However, I choose pneumonia for certain reasons. First, acute bronchitis caused by a virus does not usually produce a productive cough and bronchitis caused by bacteria is rare in healthy adults (Brashers & Huether, 2013). Viral pneumonia is often caused by a secondary infection, which I believe Tammy started with as the common cold virus (Brashers & Huether, 2013). Community-acquired pneumonia is common in otherwise healthy people who do not have contact with the health care environment (Musher & Thorner, 2014). However, the final determination of the primary diagnosis does require an x-ray to confirm. References Brashers, V. L. & Huether, S. E. (2013). Alterations of pulmonary function. In K. L. McCance, S. E. Huether, V. L. Brashers, & N. S. Rote (Ed.), Pathophysiology: The biologic basis for disease in adults and children (7th ed., pp. ). St. Louis, MO: Mosby. Musher, D. M. & Thorner, A. R. (2014). Community-acquired pneumonia. The New England Journal of Medicine, 371, . doi: 10.1056/NEJMra1312885 Jamie Miller Show Less Derek McElreathreply to Sarah Drum 9/11/2016 10:27:38 PM RE: Week 2 DB 2 Sarah, Bronchitis seems to fit the picture the best. As you mentioned, bronchitis is an inflammation in the lower respiratory track. The inflammation causes irritation and coughing. I thought your article was interesting that bronchitis is usually causes by viral infections because if that is the case then as you mentioned the 10 percent of causes being bacterial, that means that 90 percent are being mistreated or that antibiotics are being way over prescribed for these infections. "There is the potential for extensive antimicrobial use, some of which might be inappropriate" (Vergidis, Hamer, Meydalni, Dallal & Barlam, 2011). I have seen multiple cases on the recent news about the overprescribing of antibiotics. This overprescribing epidemic does have serious consequences sometimes such as other illnesses like Clostridium difficile associated disease. Its always best to make sure the treatments we offer have benefits that outweigh the risk. Vergidis, P., Hamer, D. H., Meydani, S. N., Dallal, G. E., & Barlam, T. F. (2011). Patterns of antimicrobial use for respiratory tract infections in older residents of longterm care facilities. Journal Of The American Geriatrics Society , 59(6), . doi:10.1111/j..2011.03406.x Show Less Melissa Gushard 9/6/2016 6:10:56 AM Discussion Part Two The first and most likely diagnosis for this patient is that of acute bronchitis. According to Schub (2016) the most common symptom with acute bronchitis is an abrupt onset of a mucous-generating cough. The mucous can vary in color from clear, white, yellow, green, or blood tinged. Other symptoms related to this diagnosis are that of dyspnea, wheezing, fatigue, low grade fever, chest pain/discomfort, sore throat, malaise, myalgia, and post nasal drip. This diagnosis is most likely because it has the characteristics of green mucus, chest pain/discomfort may result from the deepness of Tammy's cough, she may have post nasal drip due to her recent cold, and the scratchy throat may be the beginning of a sore throat. Although she doesn't exhibit wheezing, fever, malaise, or myalgia a this time, she may experience these issues if her cough continues to worsen. Chronic cough is another diagnosis for Tammy. McCance, Huether, Brashers, and Rote (2013) summarize that chronic cough is a cough that has lasted for more than three weeks, and can commonly be caused by post nasal drainage, nonasthmatic eosinophilic broncitis, GERD, asthma, or a heightened cough reflex sensitivity (p. 1249). Birring (2011) also report that asthma, GERD, and upper airway disorders often go along with chronic cough, but there is controversy about whether these conditions cause or exacerbate the cough. This diagnosis is likely due to the amount of time the cough has persisted, the fact that the patient may have post nasal drip, and the recent presence of and upper airway disorder. There is no mention about mucus color/amount, or discomfort with the cough listed in the research. Pneumonia is another possible diagnosis for Tammy. Thompson (2016) states that the symptoms for this diagnosis include a cough with phlegm, difficulty breathing, chest pain, fatigue, and confusion. Tammy presents with a cough with phlegm, and she may have chest pain due to the deepness and frequency of the cough. Although Tammy doesn't show many of the symptoms of pneumonia, it may be in the early stages and she may not have all the symptoms at this point. Chronic Obstructive Pulmonary Disorder (COPD) is another diagnosis that could possibly be used for Tammy's symptoms. Holmes and Murdoch (2016) summarize that COPD is usually associated with cigarette smoking, and presents with breathlesness on exertion, cough at times, and a change in sputum color. A thorough history will need to be taken to identify risk factors such as smoking to make a diagnosis of COPD. Tammy has the symptoms of coughing and green sputum color, but lacks the other symptoms of COPD at this time. Another diagnosis possible for Tammy is that of lung cancer. McCance, Huether, Brashers, and Rote (2013) state that early stage symptoms can include coughing, chest pain, excessive sputum production, pneumonia, airway obstructions, hemoptysis, plueral effusions, and weight loss. These symptoms are often reported as attributions to smoking. Although this diagnosis is least likely, if there is no other plausible reason, lung cancer should be ruled out. Tammy exhibits the coughing, excessive sputum production, likely airway obstruction due to coughing fits, gagging, and dry heaves, and chest pain could be attributed to the deepness of the cough. It is important to see if this patient smokes or has a history of smoking to help with this diagnosis (p. 1282). Schub (2016) summarizes that treatment for acute bronchitis includes promoting optimal physiologic status and reducing complications. Compling an assessment and vital signs, and prescribing medications PRN are also part of the treatment plan. Antivirals may be prescribed if the patient is suspected to have the flu, and antibiotics may be prescribed if the cause is presumed to be bacterial. The patient will also be educated about the importance of rest, hydration, nutrition, and monitoring for worsening symptoms. When Tammy reports with worsening symptoms, I would change her diagnosis to pneumonia. According to the symptoms I mentioned previously, Tammy now exhibits difficulty breathing and fever. Thompson (2016) states that bacteria are the most common causes of pneumonia in adults, and this could be causing the foul smelling mucous and breath. References Birring, S. (2011). Controversies in the evaluation and management of chronic cough. American Journal of Respiratory and Critical Care Medicine. 183 (6). 708- 715. doi: 10.1164/rccm.CI Holmes, S., & Murdoch, C. (2016). Advances in COPD: a glimpse of the future. Practice Nurse. 46(4). 1-8. Retrieved from sid=73ba6714-6b54-453b-9e0f22aab679441a%40sessionmgr120&vid=2&hid=117&bdata=JnNpdGU9ZWRz LWxpdmU%3d#AN=&db=a9h McCance, K.L., Huether, S.E., Brashers, V.L., & Rote, N.S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed). St. Louis, MO: Mosby Schub, T. (2016). Bronchitis, acute. CINHL Nursing Guide. 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