Question:

Welcome to Great Lakes Medical Center! Today, you are assigned to work in the outpatient clinic which provides general medical care to adult patients. Many of the patients seek care at the clinic because they do not have any medical insurance. Your first patient is John Kosich, a 55-year-old Caucasian male, who presents with complaints of cough, fatigue, fever of 100°F, and increased shortness of breath with activity x 5 days. Cough is productive with a large amount of thick tan sputum, worse at night when supine, occurring day and night. He reports needing two pillows to sleep at night. In addition, he experiences dyspnea with one flight of steps and intercourse. In the past, he has tried over-the-counter (OTC) Robitussin and Primatene Mist inhaler with minimal relief.
John states that he has been smoking one pack per day for 40 years.
John has COPD

Review the following readings after successfully completing the Kosich Case: Health Assessment.
Required:
• Burt, L. & Corbridge, S. (2013). COPD exacerbations: Evidence-based guidelines for identification, assessment, and management. American Journal of Nursing, 113(2), 34-43. doi: 10.1097/01.NAJ.0000426688.96330.60
• Iley, K. (2012). Improving palliative care for patients with COPD. Nursing Standard, 26(37), 40-46.

Additional Resources:
• Carlson, M.L., Ivnik, M.A., Dierkhising, R.A., O’Byrne, M.M. & Vickers, K.S. (2006). A learning needs assessment of patients with COPD. MEDSURG Nursing, 15(4), 204-212.
• Jablonski, A., Gift, A. & Cook, K.E. (2007). Symptom assessment of patients with chronic obstructive pulmonary disease. Western Journal of Nursing Research, 29(7), 845 – 863. doi: 10.1177/0193945906296547
• Cox, C. L., & Turner, R. (2010;2013;). Physical assessment for nurses (2nd;2; ed.). Ames, Iowa;Chichester, West Sussex, U.K;: Wiley-Blackwell.
o Chapter 4: Examination of the Respiratory System

Kosich Case Physical Assessment
Now that we have had an opportunity to learn a bit about Mr. Kosich, your job is to perform a complete physical assessment. You obtain the following information:
Past Medical History
No known medical, food or environmental allergies. Inguinal hernia repair in 1985. History of HTN & tibia/fibula fracture at age 9. Reports a 40-year pack history of tobacco use. Denies consumption of alcohol.
Family History
Father: Died (age 69). History of HTN, lung cancer, tobacco use. Mother: Living (age 76). History of CVA, NIDDM and obesity. Daughter: Living (age 21). No health issues.
Son: Living (age 25). No health issues.
Married 30 years. Stable relationship with wife. Claims to have a good relationship with daughter who is in college. Reports fair relationship with son who works at a local factory. His mother lives nearby and he visits her 2x/week. Reports visiting mother is a burden on his time.
Vital Signs
BP = 138/86 HR = 90
RR = 24 (shallow) T = 98.6°F
Ht = 5’10”
Wt = 250 pounds O2 sat = 92%
Alert & oriented x3
General Appearance
Skin warm, dry and intact without lesions. Ruddy facial complexion. Early fingernail clubbing. Capillary refill < 2 seconds. HEENT Tympanic membranes slightly opaque with light reflex and landmarks present. No nasal erythema or exudate. Septum midline. Nontender frontal and maxillary sinuses. Pharynx mildly erythematous with no purulent exudate. Negative lymphadenopathy. Neck supple, thyroid symmetrical without enlargement. No carotid bruits or JVD. Reports difficulty hearing – denies having hearing aid (“they are so expensive”). Respiratory AP: lateral diameter > 1:2. Moderate use of accessory muscles. Bilateral tympany on percussion. Decreased tactile fremitus. Diffuse course crackles and few scattered end expiratory wheezes throughout bilateral lung fields. Diminished breath sounds bilaterally. Negative lymphadenopathy.
Cardiovascular
S1 & S2 present – no murmur, gallop or rub noted. Denies edema.
GI
Denies constipation, diarrhea, black, tarry or bloody stools. Abdomen obese. BS present in all four quadrants. No tenderness to palpation.
Extremities
Increased pigmentation bilateral LE with mild varicosities and thickened toenails. Posterior tibial pulses 1+. Dorsalis pedis pulses 2+. No edema.
Upon assessment, the doctor confirms that Mr. Kosich does likely have COPD exacerbated by an acute respiratory infection.
He orders the following medications:
1. Septra 100 mg PO BID
2. Ipratropium (Atrovent) inhaler 2 puffs QID
3. Albuterol (Proventil) inhaler 2 puffs QID prn

Assignment
1. (2 pages) After reviewing the assessment data, what additional assessments should you perform?
• (Clearly identified all additional assessments that should be performed.)
• include at least one citation
2. (2 pages) What are treatment related issues (i.e. socioeconomic, cultural, spiritual etc.) that should be considered for Mr. Kosich?
• (Clearly and thoroughly identifies treatment related issues that should be considered.)
• include at least one citation
3. (2 pages) Great Lakes Medical Center has implemented a Chronic Care Model like the one described by Scruggs (2009). How might you transition Mr. Kosich to this model of care?
• (Clearly and thoroughly identifies a comprehensive transition plan.)
• include at least one citation
4. (2 pages) While caring for Mr. Kosich, his wife, Mary, arrives. She is upset and requests to speak with you privately. She reports that Mr. Kosich has been experiencing severe shortness of breath for some time but has been reluctant to seek medical care. When encouraged to see his doctor, he has repeatedly stated “There is nothing wrong with me. I’m just getting older.” She also reports that he is having difficulty caring for himself (i.e. activities of daily living etc.) and is frequently incontinent. Based on this additional information, how should you proceed?
• When composing your answer, please consider both the patient and his family.
• include at least one citation from the required readings, and/or other appropriate, credible resources.

5. Write a reflection that addresses the following: (1 page)
• What have you learned through the completion of this case study?
• How will this knowledge change your practice in the future?

Solution:
Introduction
Mr. Kosich a 55 years old Caucasian male presents complains of increased dyspnea, chronic cough with recently increased purulent sputum, Bilateral tympanic on percussion, Diminished breath sounds bilateral, crackles and few scattered end-expiratory wheezes throughout bilateral lung fields, fatigue, and fever of 100° These findings, along with a significant smoking history, increased AP chest diameter and prolonged expiratory phase suggests that Mr.Kosich is likely suffering from an acute exacerbation of COPD; However, other acute and chronic pulmonary disorders will need to be ruled out.
Additional Assessments
COPD is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The chronic airflow limitation that characterizes COPD is caused by a mixture of small airways disease such as obstructive bronchiolitis and parenchymal destruction, the relative contributions of which vary from person to person. Chronic inflammation causes structural changes, small airways narrowing, and destruction of lung parenchyma. A loss of small airways may contribute to airflow limitation and mucociliary dysfunction, a characteristic feature of the disease (Jablonski, Gift & Cook, 2007). The common causes of acute exacerbation of COPD Include viruses, bacteria, and air pollution. The common cold virus, respiratory syncytial virus, influenza and bacterial infection have been associated with COPD exacerbation….Please click the Paypal icon below to purchase full solution for only $10