Chronic Obstructive Pulmonary Disease (COPD) Case Study Sample

Subject Name : Medical Sciences

Introduction

The case report focuses on a 75-year-old woman, Mrs. Smith, who had a complicated medical history that included hypertension, chronic obstructive pulmonary disease (COPD), and lower limb edoema (Rawat & Sharma, 2018).She is an Indigenous Australian. In order to provide this patient with comprehensive assessment and tailored treatment plans, it is my responsibility as a healthcare professional to work in conjunction with the patient, other medical specialists, and carers. As a medical expert, the individual is crucial to the management of the patient's various medical issues. First, the healthcare professional will build a trusting rapport with the patient, ensuring she feels at ease addressing her issues. Second, they will evaluate her complete medical history, paying close attention to any comorbidities and previous therapies, as well as the onset and development of COPD, hypertension, and edema (Yadav et al., 2020). Thirdly, they will conduct a complete physical examination to evaluate the degree of lower leg edoema, gauge the severity of COPD, and track blood pressure changes.

They will then work in conjunction with other medical professionals, such as pulmonologists, cardiologists, and dietitians, to develop an extensive care plan that is suited to the individual's requirements. This patient's assessment will take into account both physical and psychological factors. To determine the severity of her COPD, they will physically examine her respiratory system, listen to her lungs, and measure her oxygen saturation levels. They will also perform a thorough examination of her lower limbs to determine the degree of edoema and look for any indications of venous insufficiency or other aggravating conditions (Sarkar et al., 2019).In terms of psychology, they will use a patient-centred approach and let the patient communicate her emotions, worries, and coping methods in relation to her ongoing medical concerns. Since chronic illnesses can have a substantial negative impact on a patient's mental health, it is essential to comprehend her mental and emotional state when creating a comprehensive treatment plan (Santana et al., 2019).

Background of the Present Illness

Mrs. Smith reports having trouble breathing over the previous five years. Physical exertion, exposure to cold air, or respiratory diseases make breathing difficulties worse. The patient claims that the severity of her breathing problems has progressively gotten worse over time, with an increase in the frequency of exacerbations during the past 12 months. In addition to this from the past two months, the patient has been seeing swelling in her lower legs. The edoema is considered to be severe in severity, making it difficult to walk and uncomfortable (Besharat et al., 2021).The situation of the patient becomes severe when the patient is sitting or standing for a long time. The patient also has hypertension for ten years, according to a diagnosis. She has been taking the recommended antihypertensive meds as instructed. The patient acknowledges that she occasionally forgets to take her pills. The patient has a constant cough, especially in the morning, and produces clear or white sputum. She describes an increase in mucus production during exacerbations, which occasionally turns yellow or green. The patient occasionally gets chest tightness and wheezing when they are out of breath.

Vitals

Depending on the degree of her hypertension and how well she takes her meds, Mrs. Smith's blood pressure readings may change. She has consistently high blood pressure readings of 150/90 mmHg or more. The degree of airflow restriction and exacerbations affect a COPD patient's heart rate. Mrs. Smith's resting heart rate may be within normal ranges, perhaps between 70 and 80 bpm, but it could rise during exacerbations or times when dyspnea is worse. On examination, her RR is 25–30 bpm due to increased work of breathing during exacerbations or physical exercise. Mrs. Smith's oxygen saturation levels could change due to her COPD and the possibility of desaturation during physical activity. Her resting SpO2 range is 95–97%, but after exertion or exacerbations, it falls to 88–90% (Al-Halhouli et al., 2021). Her lower leg edoema is moderate, and pitting edoema is palpable. After extended standing or sitting, the edoema spread from the ankles to the lower calves and become more obvious.

Previous Medical History

Five years ago, the patient received a diagnosis of COPD also known as chronic bronchitis. She has been using thyroid hormone replacement medication for 15 years to treat her hypothyroidism. She has a known allergy to penicillin, which results in skin rashes. Mrs. Smith has chronic joint pain and stiffness caused by osteoarthritis. Her father developed COPD in his later years due to a family history of the disease. Hypertension was observed in her mother. Mrs. Smith had smoked for 40 years before quitting 10 years prior. She eats a balanced diet but acknowledges that she occasionally indulges in salty foods. She has limited physical activity due to joint pain and shortness of breath.

Inclusion

It is crucial to understand and respect the patient's Indigenous Australian health beliefs and practises when giving healthcare to Mrs. Smith with COPD, lower leg edoema, and hypertension. The assessment and treatment plan become more culturally aware and efficient by including Indigenous health viewpoints. This part will focus on how to include the patient's Indigenous Australian health beliefs into their care (Coombs et al., 2022). Healthcare professionals should use culturally competent communication to establish a safe environment for people of all cultures. This involves utilising appropriate language that is consistent with Indigenous cultural values, actively listening, and demonstrating respect for the patient's views and experiences. Storytelling or "yarning" can be a helpful technique to build rapport and trust, enabling the patient to speak more frankly about her health concerns (Dawson et al., 2022). In Indigenous cultures, the entire community, including family members and elders, frequently participates in making decisions. Indigenous Australians have a long history of employing traditional treatments and bush medicines to treat a variety of illnesses. Healthcare professionals should inquire about her acquaintance with these practices as part of the treatment plan and, where suitable, include them into the overall care plan (Wyndow et al., 2022).

This could entail recognising the usage of certain healing rites or incorporating cultural healers. Indigenous people's health beliefs place a strong emphasis on a holistic understanding of health that takes into account the interdependence of one's physical, emotional, social, and spiritual well-being. By treating Mrs. Smith's emotional and social needs in addition to her physical issues, healthcare practitioners should adopt this strategy. In order to enhance her general wellbeing, this may entail connecting her with support groups or social services (M Bernardes et al., 2020). Mrs. Smith's relationship to her native country and homeland is very important to her health views. Having this link acknowledged and respected can improve their sense of identity and belonging, which will benefit her mental and emotional health. Indigenous health ideologies that place a high importance on individual accountability and self-determination are in line with the empowerment of her to actively engage in the treatment plan. Healthcare professionals can collaborate with her to establish realistic health objectives and offer culturally competent health education (Shepherd et al., 2018).

Discussion

The patient's background includes her medical history, surgical history, allergies, social history, and family history. She is a 75-year-old female with COPD, lower leg edoema, and hypertension. Each of these elements offers a crucial background for comprehending her present state of health and for directing the assessment and treatment strategy. The patient's past medical history details any pertinent illnesses she had to deal with in the course of her life. She has a number of serious conditions like COPD which is characterised by restricted airflow, which causes breathing problems, a persistent cough, and increased mucus production. Mrs. Smith has untreated hypertension that can raise the risk of cardiovascular events (Sarkar et al., 2019). It is characterised by persistently high blood pressure. There is no surgical history seen or mentioned by the family members. Mrs. Smith;s family states that they are aware of a penicillin allergy, which might result in skin rashes or more serious responses. It's critical to be aware of this sensitivity in order to avoid prescription drugs that include penicillin or similar antibiotics that can cause a negative reaction. The patient's social history sheds light on a variety of lifestyle choices and environmental circumstances that could affect her health. Her 40-year history of smoking has contributed to the onset of COPD and hypertension, despite the fact that she is no longer a smoker. Understanding her eating patterns, including the sporadic indulgence in salty foods, can be helpful in treating her edoema and hypertension. Her general health and well-being may be impacted by her limited physical activity due to shortness of breath and joint pain from osteoarthritis. The patient's family history reveals important details about genetic diseases and potential risk factors for certain health problems. Her father had COPD, raising the possibility of a genetic predisposition to the disease.Her mother's history of high blood pressure and stroke suggests a family susceptibility to cardiovascular problems, which may increase her chance of developing high blood pressure.

Assessment Findings

Physical and psychological assessment

Mrs. Smith consistently has breathing problems, especially when she is active or exposed to chilly air. She has a persistent cough that frequently produces clear or white sputum and that gets worse in the morning.During worsening episodes of dyspnea, wheezing and chest tightness may be present. During exacerbations, Mrs. Smith describes increased mucus production, with the sputum occasionally turning yellow or green. Mrs. Smith consistently has elevated blood pressure readings.Hypertension can result in headaches, especially first thing in the morning or right after stressful events. Due to her elevated blood pressure, she can feel lightheaded or dizzy. After prolonged standing or sitting, Mrs. Smith detects swelling in her lower legs, which is more obvious. Low energy levels and persistent exhaustion are side effects of hypothyroidism. Even though Mrs. Smith's diet and exercise routine haven't changed significantly, she can nevertheless experience unexplained weight gain. Mrs. Smith has limited joint mobility, stiffness, and persistent joint discomfort (WHO, 2023).

Results in the respiratory system

Reduced breath sounds, longer expiration, and the presence of bilateral wheezes are signs of COPD-related obstructive lung disease. The results of the spirometry test show decreased forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), along with an elevated FEV1/FVC ratio, which confirms the existence of an airflow blockage. When she is exerting herself, her oxygen saturation levels fluctuate, which indicates poor gas exchange. The reliable indicator of hypertension is elevated blood pressure. Electrocardiogram (ECG) may be used to evaluate the patient's heart rhythm and spot any indications that her ailment may be cardiac-related (Deepak et al., 2017).

Recommendations

The following diagnoses have been determined based on Mrs. Smith’s subjective and objective data. It is crucial to take into account potential differential diagnoses for the patient's symptoms in order to provide thorough care. It is important to thoroughly assess any potential coexisting conditions with COPD, hypertension, and edoema in order to rule them out. Use of diagnostic studies should be prudent in order to confirm the main diagnoses and rule out any possible differentials (Tomasic et al., 2018). Assessing lung function and confirming the diagnosis of COPD by spirometry and pulmonary function testing. ECG to evaluate her diseases' impact on her heart rhythm and cardiac involvement. She underwent tests to assess her general health, including CBC, electrolyte levels, thyroid function, and kidney function. X-ray of the chest or a CT scan to examine the structure of the lungs and rule out other pulmonary diseases. Mrs. Smith’s particular needs, preferences, and health beliefs should be taken into account when creating the treatment plan. The following elements should be part of a person-centred, evidence-based strategy. First is management of COPD which includes treatment of airflow blockage and lessen exacerbations, prescribe bronchodilators and corticosteroids inhaler forms.Refer the patient to pulmonary rehabilitation to increase their capacity for exercise and their respiratory muscle strength. Secondis treatment of hypertension by encouraging regular exercise, a low-sodium diet, and stress-reduction methods as part of your lifestyle changes to control your blood pressure (King, 2017).

Prescribe the proper antihypertensives while taking into account any potential interactions with COPD medicines. Encourage regular blood pressure checking, either at home or in a medical facility. Third is treatment of lower leg edoema by encouraging Mrs. Smith to elevate her legs and wear compression stockings to help with swelling reduction. Fourthis to control joint pain and increase mobility, think about non-pharmacological interventions including physical therapy and assistive technology. Management of hypothyroidism should include proper thyroid hormone replacement therapy and ongoing monitoring. Fifth is to plan frequent follow-up appointments to monitor therapy effectiveness, modify medications, and handle any emerging issues. Keep the lines of communication open, actively including the patient in decision-making, and addressing any obstacles to adherence (Yao & Kabir, 2023).

Conclusion

The case study of Mrs. Smith, an Indigenous Australian woman in her 75s with COPD, hypertension, and lower limb edoema, illustrates the need for a person-centred approach to healthcare. A thorough treatment plan was created to address her many medical issues by using evidence-based practises and honouring her cultural beliefs and preferences. A careful use of investigations, including spirometry, ECG, and blood tests, was necessary to establish Mrs. Smith's diagnosis of COPD with characteristics of chronic bronchitis, hypertension, and lower limb edoema and rule out any differentials. Healthcare professionals were able to better comprehend her health status thanks to these diagnostic tests and a careful review of her medical history, which helped them create a personalised treatment plan. The person-centered treatment plan placed a strong emphasis on providing holistic care, which included managing COPD with inhaler therapy and pulmonary rehabilitation, controlling hypertension with dietary changes and antihypertensive drugs, and managing edoema with elevation and compression techniques as well as diuretics when necessary. The plan also included provisions for the management of comorbid illnesses like osteoarthritis and hypothyroidism. The effectiveness of this treatment approach depended on maintaining contact with Mrs. Smith, including her in the decision-making process, and actively addressing any obstacles to adherence. A crucial part of assessing the effectiveness of the treatment, making the necessary adjustments, and maintaining her comfort and well-being was regular follow-up and monitoring.

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