Common Respiratory Disorders in Primary Care

Common© Jones Respiratory & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC DisordersNOT FOR in SALE Primary OR DISTRIBUTION Care NOT FOR SALE OR DISTRIBUTION Joanne L. Thanavaro © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Case 1 - Influenza D. Guidelines to direct care: Global Initiative for Asthma 2015 and National Heart Lung and Blood Institute (NHLBI) Guide- A. History and Physical© Exam Jones & Bartlett Learning, LLClines for the Diagnosis and Management© Jones of & Asthma Bartlett (EPR-3) Learning, LLC B. Recommended Lab/DiagnosticsNOT FOR SALE OR DISTRIBUTIONE. Treatment Plan NOT FOR SALE OR DISTRIBUTION C. Pathophysiology D. Guidelines to direct care: Prevention and control of seasonal Case 4 - Chronic Obstructive Pulmonary influenza with vaccines: recommendation of the Advisory Disease (COPD) Committee on Immunization Practices (ACIP) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC E. Treatment Plan A. History and Physical Exam NOT FOR SALE OR DISTRIBUTION B. RecommendedNOT FORabs/Diagnostics SALE OR DISTRIBUTION Case 2 - Acute Bronchitis C. Pathophysiology D. Guidelines to direct care: Global Initiative for Chronic A. History and Physical Exam Obstructive Lung Disease (2015) B. © Jones & Bartlett Recommended Learning, Labs/Diagnostics LLC © JonesE. Treatment & Bartlett Plan Learning, LLC NOT FOR C.SALE Pathophysiology OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION D. Guidelines to direct care: Chronic Cough Due to Acute Case 5 - Community-Acquired Pneumonia (CAP) Bronchitis: American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines A. History and Physical Exam E. Treatment Plan © Jones & Bartlett Learning, LLCB. Recommended Labs/Diagnostics© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONC. Pathophysiology NOT FOR SALE OR DISTRIBUTION Case 3 - Asthma D. Guidelines to direct care: Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines A. History and Physical Exam on the Management of Community-Acquired Pneumonia B. Recommended Labs/Diagnostics in Adults C. Pathophysiology© Jones & Bartlett Learning, LLC E. Treatment© Jones Plan & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 33 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 33 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 34 CHAPTER 3 | Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Learning Objectives

Using a case-based approach, the learner will be able to: 3. State pathophysiology of common pulmonary disorders. 1. Identify key history and physical examination parameters for 4. Document a clear, concise SOAP note for patients with com- © Jones & Bartlett Learning, LLCmon pulmonary disorders. © Jones & Bartlett Learning, LLC common pulmonaryNOT disorders FOR seen SALE in primary OR care DISTRIBUTION includ- NOT FOR SALE OR DISTRIBUTION ing influenza, acute bronchitis, asthma, COPD, and CAP. 5. Identify relevant education and counseling strategies for pa- 2. Summarize recommended laboratory and diagnostic studies tients with common pulmonary disorders. indicated for the evaluation of common pulmonary disorders 6. Develop a treatment plan for common pulmonary disorders seen in primary care. utilizing current evidence-based guidelines. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Case 1

© Jones &Mrs. Bartlett Cleaver is aLearning, 48-year-old female LLC who comes to the office accom©- JonesRunny & noseBartlett Learning, LLC NOT FORpanied SALE by her OR husband. DISTRIBUTION She’s complaining of fatigue, fever, and chillsNOT FORNasal congestionSALE OR DISTRIBUTION for the last 2 days. She recently returned home from California where Muscle or body aches she was taking care of her three grandchildren for the last 3 weeks. She Headaches reports that the kids all had “colds” but got better without treatment. Her past medical history (PMH) is remarkable for idiopathic cardio- Fatigue myopathy, diabetes mellitus© type Jones 2, and &hypertension. Bartlett She Learning, is a non- LLCVomiting and diarrhea (more common© Jones in children) & Bartlett Learning, LLC smoker and nondrinker. She has not been able to exercise since she NOT FOR SALE OR DISTRIBUTIONPhysical Exam NOT FOR SALE OR DISTRIBUTION returned home because of her extreme tiredness. Her medications include: carvedilol 6.25 BID, lisinopril 20 mg, and aldactone 25 mg For patients with comorbid conditions, be sure to evaluate for any daily. She planned to get her influenza vaccine sometime next week. worsening of underlying conditions. In this patient, it is important not only to rule out pneumonia but also to evaluate for heart fail- Physical Exam © Jones & Bartlett Learning, LLC ure and uncontrolled© Jones diabetes. & Bartlett Learning, LLC Vital Signs: Blood pressure (BP) 126/76, heart rate (HR) 65, NOT FOR SALE OR DISTRIBUTION RoutineNOT Labs/Diagnostics FOR SALE OR DISTRIBUTION respiratory rate (RR) 12, temperature (T) 99.8. General (GEN): No acute distress Ñ The Centers for Disease Control and Prevention (CDC), Eyes, ears, nose, and throat (EENT): Pharyngeal redness without exu- World Health organization (WHO), and Infectious Disease dates. Tympanic membranes (TMs) without bulging or fluid lines Society of America recommend that healthcare providers di- © Jones & Bartlett Learning, LLC © Jonesagnose & Bartlett influenza clinically.Learning, LLC Heart: S1 and S2 regular rate and rhythm (RRR) with pansystolic NOT FOR SALEmurmur OR along DISTRIBUTION the left sternal border NOT FORÑ Testing SALE is recommended OR DISTRIBUTION for: Ñ Hospitalized patients with influenza-like illnesses Lungs: Clear to auscultation Ñ Patients who died of an influenza-like illness (to clarify Abdomen: Soft, nontender with good bowel sounds etiology) What additional assessments/diagnostics do you need? Ñ Patients for whom decisions about infection control and What is the differential© diagnoses Jones list?& Bartlett Learning, LLC treatment of close contacts© isJones a concern &1–3 Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION What is your working diagnosis? Ñ Sensitivities of rapid diagnostic tests are approximately 50–70% when compared with viral culture or reverse tran- Additional Assessments/Diagnostics scription polymerase chain reaction (RT-PCR); specifici- Needed ties of rapid diagnostic tests for influenza are appropriately © Jones & Bartlett Learning, LLC 90–95%.© Jones & Bartlett Learning, LLC ReviewNOT FOR of Systems SALE (ROS)OR DISTRIBUTION Ñ False-positiveNOT (andFOR true-negative) SALE OR results DISTRIBUTION occur more fre- Ask about common signs and symptoms of influenza, including: quently when disease prevalence in the community is low, usually at the beginning and end of the flu season. Fever/chills Ñ False-negative (and true-positive) results occur more fre- Cough quently when disease prevalence is high in the community, © Jones &Sore Bartlett throat Learning, LLC © Joneswhich & Bartlett is usually at Learning, the height of the LLC flu season.4 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 34 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 34 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 1 35 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEDifferential OR DISTRIBUTION Diagnoses List NOT FORÑ CanSALE lessen OR symptoms DISTRIBUTION and reduce duration of symptoms by 1–2 days Upper respiratory tract infection Ñ Can prevent serious flu-related complications for people Influenza with high-risk health conditions Working Diagnosis—Influenza Ñ Side effects include nausea, vomiting, diarrhea, dizziness, © Jones & Bartlett Learning, LLC cough, and headache6 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pathophysiology Nonpharmacologic Influenza is a contagious respiratory illness caused by the in- Ñ Drink plenty of liquidschoose water, juice, and warm fluenza viruses that infect the nose, throat, and lungs. Viruses soups to prevent dehydration. Drink enough liquid so that spread mainly by droplets when people cough, sneeze, or talk. your urine is pale yellow or clear. Contagiousness© Jones of &influenza Bartlett occurs Learning, 1 day before LLC symptoms to © Jones & Bartlett Learning, LLC Ñ 5–7 daysNOT after FOR illness. SALE These viruses OR DISTRIBUTION are unpredictable, and their Rest. NOT FOR SALE OR DISTRIBUTION severity can vary widely from season to season. Older people; Ñ Consider pain relievers such as Tylenol (acetaminophen) or 7 children; pregnant women; people with asthma, chronic ob- ibuprofen to help with body aches. structive pulmonary disease (COPD), diabetes, or heart, kidney, Education/Counseling or neurologic disease; and people with weakened immune sys- © Jones &tems Bartlett (HIV, AIDS, Learning, cancer, or chronicLLC steroid use) are at greater© JonesÑ The & bestBartlett way to prevent Learning, influenza LLC is to get a flu vaccine every NOT FORrisk SALE for serious OR complications. DISTRIBUTION Complications of flu include bacNOT- FORseason. SALE OR DISTRIBUTION terial pneumonia, sinus infections, dehydration, worsening of Ñ Yearly flu vaccination is ideally by October. chronic medical conditions, and death.5 Ñ It takes 2 weeks after vaccination for antibodies to develop that protect against infection. What Is Your Treatment© Jones Plan?& Bartlett Learning, LLCÑ Everyone 6 months of age and© Jonesolder should & Bartlettget a flu vaccine Learning, LLC NOT FOR SALE OR DISTRIBUTIONevery year. NOT FOR SALE OR DISTRIBUTION Pharmacologic Ñ Reinforce that you can’t get the flu from a flu shot. Ñ Side effects that can occur include soreness, redness, or swell- Ñ Annual flu vaccines ing at the injection site, low-grade fever, and body aches. Life- Ñ Trivalent flu vaccineprotects against two influenza A vi- threatening allergic reactions are very rare and may include ruses© Jones (an H1N1 & Bartlettand an H3N2) Learning, and an influenza LLC B virus. breathing© problems,Jones &hoarseness, Bartlett wheezing, Learning, hives, tachycarLLC - AvailableNOT FOR vaccines SALE include: OR DISTRIBUTION dia, or dizziness.NOT FOR These SALEreactions ORoccur DISTRIBUTIONamong persons with a Ñ Standard-dose trivalent shots (IIV3) that are manufac- severe allergy to eggs and usually occur within a few minutes 7 tured using virus grown in eggs to a few hours after administration. Ñ Intradermal trivalent shotapproved for people 18 SOAP Note through 64 years of age © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Ñ High-dose trivalent shotapproved for people 65 years S: Mrs. Cleaver presents today with a 2-day history of fatigue, fe- NOT FOR SALEand OR older DISTRIBUTION NOT FORver, SALEand chills. OR She DISTRIBUTIONrecently returned home from babysitting Ñ Trivalent shot containing virus grown in cell culture her grandchildren, who all had “colds.” She has a sore throat, approved for people 18 years and older nasal congestion, and a mild headache. She denies cough, vomiting, diarrhea, chest pain, shortness of breath (SOB), Ñ Recombinant trivalent shot that is egg freeapproved for ankle swelling, or lightheadedness. Her blood sugars have people 18 years and older © Jones & Bartlett Learning, LLCbeen slightly elevated from© her Jones normal fasting& Bartlett blood sugar Learning, LLC Ñ Quadrivalent flu vaccineprotectsNOT FOR SALE against ORtwo DISTRIBUTIONinfluenza (FBS) range of 130–140, andNOT she continues FOR SALE to eat and OR drink DISTRIBUTION A viruses and two influenza B viruses. Available vaccines without difficulty. She has continued all her regular medica- include: tions. She has not had her annual flu vaccine yet. Ñ Quadrivalent flu shot O: Vital Signs: BP 126/76, HR 65, RR 12, T 99.8 Ñ Quadrivalent nasal sprayapproved for people 2 through GEN: No acute distress © 49Jones years of &age Bartlett Learning, LLC © Jones & Bartlett Learning, LLC EENT: No redness or crusting of eyes. TMs without bulging or Ñ NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Antiviral drugs fluid lines in bilateral ears. Pharyngeal redness without exu- Ñ Two antiviral drugs recommended by the CDC dates. No thyromegaly or carotid bruits Ü Oseltamivir (Tamiflu) and Zanamir (Relenza) Heart: S1 and S2 RRR with pansystolic murmur along the left Ñ If used, should be started within 2 days of initial symptoms sternal border unchanged from previous exam. Point of maxi- © Jones & Bartlettand taken Learning, for at least 5 daysLLC © Jonesmal & impact Bartlett (PMI) Learning, minimally displaced LLC laterally NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 35 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 35 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 36 CHAPTER 3 | Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALELungs: Clear OR to DISTRIBUTION auscultation. No crackles, fremitus, or egophNOT- FORDrink SALE plenty ORof fluids. DISTRIBUTION Tylenol (acetaminophen) for muscle ony. No dullness to palpation aches. Monitor blood sugars daily. Continue all other medica- Abdomen: Soft, nontender with good bowel sounds tions as before. Call back if symptoms don’t gradually improve Extremities: Full range of motion of all extremities. No leg edema. over the next week or if she develops SOB or chest pain or is Dorsalis pedis and posterior tibialis pulses +2. No open lesions unable to eat or drink. on feet © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Health Promotion Issues Neuro: Alert and orientedNOT × 3 FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Recent Labs (1 month ago): Blood urea nitrogen (BUN) 10, Ñ Annual influenza vaccination creatinine (Cr) 0.8, potassium (K) 4.0, hemoglobin A1c 6.0 A: Likely influenza: Day 2 Guidelines to Direct Care Cardiomyopathy:© Jones & Stable Bartlett Learning, LLC Advisory ©Committee Jones for& BartlettImmunization Learning, Practices (ACIP).LLC DiabetesNOT mellitus FOR type SALE 2: Controlled OR DISTRIBUTION ACIP vaccineNOT FORrecommendations. SALE OR DISTRIBUTIONhttp://www.cdc.gov/ Hypertension (HTN): At Eighth Joint National Committee vaccines/hcp/acip-recs/. Accessed September 16, 2015. (JNC 8) goals Grohskopf LA, Olsen SJ, Sokolow LZ, et al. Prevention and P: Discussed rationale for use of antivirals, given her PMH control of seasonal influenza with vaccines: recommenda- © Jones & Bartlettof cardiomyopathy Learning, and diabetes LLC mellitus (DM). Oseltamivir© Jonestions & Bartlettof the Advisory Learning, Committee LLC on Immunization Practices 75 mg BID × 5 days. Quadrivalent influenza vaccine today for (ACIP)United States, 2014–15 influenza season. MMWR. NOT FOR SALEboth patient OR DISTRIBUTION and husband. Reviewed possible side effects ofNOT FOR2014;63(32):691–697. SALE OR DISTRIBUTION http://www.cdc.gov/mmwr/preview/ antiviral drug and influenza vaccine. Discussed measures to mmwrhtml/mm6332a3.htm. Accessed September 16, 2015. prevent spread of virus (hand washing, covering sneezes).

Mr. Gretsky is a 60-year-old engineer who comes to the clinic clinically. Sputum cytology may be helpful if the cough is persis- stating he has been feeling terrible for the last 4 days. He reports tent. Chest X-ray (CXR) should be performed only in patients having© cold Jones symptoms, & Bartlett including aLearning, sore throat, runny LLC nose, body whose physical© examinationJones & isBartlett suggestive ofLearning, pneumonia. LLC aches,NOT and fatigue. FOR His SALE cough ORwas initiallyDISTRIBUTION dry, but now he has DifferentialNOT Diagnosis: FOR SALE OR DISTRIBUTION some yellowish sputum. His cough is making it difficult for him to speak and is interfering with his ability to work. Last evening Acute bronchitis he developed pain in the left side of his chest when he coughs. Allergic rhinitis His PMH is significant only for hypertension. He takes lisinopril Asthma © Jones &20 mgBartlett daily. He Learning, denies alcohol LLCuse and quit smoking 20 years ago.© JonesCOPD & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Physical Exam Common cold Influenza Vital Signs: BP 140/88, HR 88, RR 14, T 98.1 Congestive heart failure exacerbation HEENT: Mild pharyngeal erythema Gastroesophageal reflux disease Heart: S1 and S2 RRR without© Jones gallops, & murmurs, Bartlett or rubsLearning, LLCOccupational exposures © Jones & Bartlett Learning, LLC Lungs: Clear to auscultation.NOT No FOR dullness SALE to percussion OR DISTRIBUTION Malignancy NOT FOR SALE OR DISTRIBUTION Abdomen: Soft, nontender with good bowel sounds (BS) What additional assessments/diagnostics do you need? Working Diagnosis—Acute bronchitis What is the differential diagnoses list? Pathophysiology What© isJones your working & Bartlett diagnosis? Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Cough is theNOT most FORcommon SALE symptom OR compelling DISTRIBUTION patients to Additional Assessments/Diagnostics come to the office for treatment. Acute bronchitis is an acute respiratory infection with a normal chest radiograph that is mani- Needed fested by cough with or without phlegm production that lasts for Acute bronchitis may be suspected in patients with an acute re- up to 3 weeks. Because many illnesses also present with a cough, © Jones &spiratory Bartlett infection Learning, with cough, LLC and the diagnosis can be made© Jonesthis diagnosis & Bartlett can be difficultLearning, to distinguish LLC from other illnesses. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 36 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 36 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 2 37 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORThe SALE evaluation OR of DISTRIBUTION adults with an acute cough illness, or with preNOT- FORÑ ConsiderSALE aOR delayed DISTRIBUTION “wait-and-see prescription” for antibi- sumptive diagnosis of uncomplicated acute bronchitis, should otics. Instruct patients to not fill prescription until at least focus on ruling out pneumonia. 7–10 days, when symptoms are likely to subside without Chronic bronchitis is defined by a productive cough that treatment. lasts at least 3 months per year for at least 2 consecutive years. Ñ Provide information sheets for symptom management, The presence of purulent© Jonessputum is & not Bartlett predictive Learning, of bacte- LLC viral infections and antibiotics,© Jones and ensuring & Bartlett close follow- Learning, LLC rial infection. GastroesophagealNOT FOR reflux SALE disease OR also DISTRIBUTIONcauses a up by phone or a scheduledNOT follow-up FOR visit. SALE9 OR DISTRIBUTION cough but is usually associated with increased symptoms at night, heartburn, and a sour taste in the mouth. More than SOAP Note 90% of cases of acute cough illness are nonbacterial. Viral eti- Mr. Gretsky is a 60-year-old patient who reports having cold ologies include influenza, parainfluenza, respiratory syncytial S: symptoms, including a sore throat, runny nose, body aches, virus ©(RSV), Jones and adenovirus;& Bartlett bacterial Learning, agents includeLLC Borde- © Jones & Bartlett Learning, LLC and fatigue for the last 4 days. He developed a cough, which tella, NOTpertussis, FOR Mycoplasma SALE ORpneumoniae DISTRIBUTION, and Chlamydophila NOT FOR SALE OR DISTRIBUTION 8 now is occasionally productive of yellowish sputum. Cough is pneumonia. his worse symptom, and it’s making it difficult for him to work. What Is Your Treatment Plan? His cough was initially dry, but now he has some yellowish sputum. He also has left-sided chest pain when he coughs. He Treatment of acute bronchitis is divided into prescribing antibiot- had his flu vaccine 1 month ago at his work health clinic. © Jones &ics Bartlettand symptom Learning, management. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORO: Vital SALE Signs: BP OR 140/88, DISTRIBUTION HR 88, RR 14, T 98.1 Pharmacologic GEN: No acute distress. Coughing frequently with occasional Antibiotics:9 yellowish sputum. EENT: Eyes without redness or crusting. Ears no redness, TMs Ñ Not routinely indicated and should be avoided to minimize normal without bulging or fluid line. Nasal turbinates mildly antibiotic resistance and infection. © JonesClostridium & difficileBartlett Learning, LLCred with serous drainage. Pharynx© Jones red with & Bartlett+1 tonsils with Learning,- LLC Ñ Guidelines suggest aNOT trial of FORan antitussive SALE medication OR DISTRIBUTION (such out exudates. NOT FOR SALE OR DISTRIBUTION as codeine, dextromethorphan, or hydrocodone) (American Heart: S and S RRR without murmurs, gallops, or rubs College of Chest Physician [ACCP] Guidelines).10 1 2 Lungs: Clear to auscultation. No egophony or fremitus. No dull- Ñ Although commonly used, expectorants and inhaler medica- ness to percussion. No wheezing tions are not recommended for routine use. Abdomen: Soft, nontender with good bowel sounds Ñ Beta-agonist© Jones inhalers& Bartlett may be Learning, beneficial for LLC patients with © Jones & Bartlett Learning, LLC No edema wheezing.NOT FOR SALE OR DISTRIBUTION Extremities:NOT FOR SALE OR DISTRIBUTION A: Acute bronchitis Ñ There are no data to support the use of oral corticosteroids. HTN: At JNC 8 guideline goals Ñ Pelargonium (also known as kalwerbossie, South African geranium, or rabassam) was shown to improve return to Prior smoker work in patients (2 days earlier) compared to those taking P: Discussed the nature of acute bronchitis. Explained that anti- © Jones & Bartlett placebo.10, Learning, 11 LLC © Jonesbiotics & Bartlett are not indicated Learning, for bronchitis LLC even with discolored NOT FOR SALE OR DISTRIBUTION NOT FORsputum. SALE Given OR CDC DISTRIBUTION patient handout on avoidance of antibi- Nonpharmacologic otics for viral conditions. Drink plenty of fluids and rest. Ty- lenol for chest wall pain. Try dark honey for symptom relief. Ñ Drink plenty of fluids Pelargonium may also be used. Congratulate patient for his Ñ Dark honey for symptom relief continued smoking cessation. Given anticipatory guidance © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Education/Counseling regarding likelihood of cough lasting for another 7–10 days. NOT FOR SALE OR DISTRIBUTIONCall back if symptoms don’tNOT gradually FOR decrease. SALE OR DISTRIBUTION Ñ Many healthcare providers are reluctant to not prescribe antibiotics because it is difficult convincing patients that antibi- Health Promotion Issues otics are usually ineffective against acute bronchitis. Ñ Discuss importance of annual influenza vaccine. Ñ Methods for managing patient expectations for medication Ñ Wash hands frequently and practice good hygiene. to© treat Jones acute bronchitis& Bartlett include: Learning, LLC © Jones & Bartlett Learning, LLC ÑNOT Define FOR the illness SALE as a “chestOR DISTRIBUTION cold” or “viral upper respira- GuidelinesNOT FORto Direct SALE Care OR DISTRIBUTION tory infection.” Braman SS. Chronic cough due to acute bronchitis: ACCP Ñ Instruct patients that symptoms may last about 3 weeks. evidence-based clinical practice guidelines. Chest. 2006; Ñ Explain that antibiotics don’t reduce duration of symp- 129(1 suppl):95S–103S. http://journal.publications.chestnet © Jones & Bartletttoms and Learning, may cause side LLC effects or antibiotic resistance.© Jones.org/data/Journals/CHEST/22039/95S.pdf & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 37 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 37 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 38 CHAPTER 3 | Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECenters for OR Disease DISTRIBUTION Control and Prevention. Acute cough illnessNOT FORprint-materials/hcp/adult-acute-cough-illness.html. SALE OR DISTRIBUTION Accessed (acute bronchitis) physician information sheet (adults). http:// September 16, 2015. http://www.cdc.gov/getsmart/campaign- www.cdc.gov/getsmart/community/materials-references/ materials/info-sheets/adult-acute-cough-illness.pdf

Jennifer is a 27-year-old slender white female who presents today Ñ Symptoms occur or worsen in the presence of exercise, viral with a complaint of a chronic cough of more than 2 months and infection, animals with fur or hair, house dust mites (in mat- shortness© Jones of breath. & Sometimes Bartlett the Learning, cough produces LLC clear phlegm. tresses, pillows,© Jones etc.), &mold, Bartlett smoke (tobacco/wood), Learning, LLC pollen, Her episodesNOT FORof SOB SALEare occurring OR more DISTRIBUTION often, up to several times changes NOTin weather, FOR strong SALE emotional OR DISTRIBUTIONexpression (laughing a week, and it seems to take longer for her to recover. She has dif- or crying), airborne chemicals or dusts, menstrual cycles ficulty breathing at night and can sometimes hear a “wheezing Ñ Symptoms occur or worsen at night, awakening the patient sound.” It occasionally feels like there is “a band around my chest 12 and it’s frightening.” She has also been very tired lately and has a Classify asthma severity. See Table 3-1. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC decreased appetite. Jennifer smokes 2 packs of cigarettes a day, a Physical Exam NOT FORhabit SALE she began OR at DISTRIBUTION 15 years of age. NOT FOR SALE OR DISTRIBUTION Physical exam (PE) given is adequate to start dx list and treatment Physical Exam (tx) plan Vital Signs: BP 104/64, HR 94 (regular), RR 20, T 97.6 Routine Labs/Diagnostics Needed © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC EENT: Visual fields and extraocular movements (EOMs) intact. Ñ Pulmonary function test was done after bronchodilation TMs translucent, gray,NOT light FORreflex and SALE landmarks OR visible,DISTRIBUTION no with albuterol NOT FOR SALE OR DISTRIBUTION fluid. Nose: Mucosa pink, clear discharge, no polyps. Mouth: Ratio of forced expiratory volume in 1 second to forced vital No pharyngeal edema, exudates, or lymphadenopathy. No capacity (FEV1/FVC) <70% of predicted frontal/maxillary sinus tenderness. Negative transillumination FEV1 56% of predicted Lungs: Resonant to percussion, lung expansion equal. No in- © Jones & Bartlett Learning, LLC Ñ Allergy testsused© Jones to & document Bartlett specific Learning, allergens suggested LLC crease in anteroposterior (AP)/lateral diameter. Diffuse by clinical history or to reinforce need for environmental expiratoryNOT FOR wheezes SALE bilaterally. OR DISTRIBUTION No voice sounds or tactile NOT FOR SALE OR DISTRIBUTION control (not done in this patient) fremitus

CV: S1, S2 RRR, no murmurs, rubs, or gallops Abdomen: Nontender, no masses or guarding. BS+ Differential Diagnoses List © Jones &Neuro: Bartlett No tremors, Learning, strength LLC 5/5. Tender paracervical muscles© JonesCOPD & Bartlett Learning, LLC NOT FOR SALEto palpation OR DISTRIBUTION NOT FORAsthma SALE OR DISTRIBUTION Extremities: No edema, pulses 2+ CHF What additional assessments/diagnostics do you need? Pulmonary embolism What is the differential diagnoses list? Mechanical obstruction of the airways (benign and malignant What is your working ©diagnosis? Jones & Bartlett Learning, LLCtumors) © Jones & Bartlett Learning, LLC Pulmonary infiltration with eosinophilia NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Additional Assessments/Diagnostics Needed Cough secondary to drugs Vocal cord dysfunction ROS Working Diagnosis ROS that focuses on the following key indicators for a diagnosis (dx) © Jones & Bartlett Learning, LLC Moderate persistent© Jones asthma & Bartlett Learning, LLC of asthma:NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ñ Wheezing Pathophysiology Ñ History of any of the following: cough, worse particularly Asthma is a chronic inflammatory disorder of the airways that in- at night, recurrent wheeze, recurrent difficulty in breathing, volves the interaction of airflow obstruction, bronchial hyperre- recurrent chest tightness sponsiveness, and underlying inflammation. The interaction of these © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 38 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 38 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 3 39 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORTABLE SALE OR3-1 DISTRIBUTIONClassiﬁcation of Asthma Severity NOT FOR SALE OR DISTRIBUTION Classiﬁcation of Asthma Severity (patients age 12 years or older) Persistent Components of Severity Intermittent Mild Moderate Severe © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Impairment Symptoms <2 days/week >2 days/week Daily Throughout the day NOT FOR SALE OR DISTRIBUTIONbut not daily NOT FOR SALE OR DISTRIBUTION Normal FEV1/ FVC: 8–9 y 85%, Nighttime ≤2 times/month 3–4 times/month >1 time/week, but not Often 7 times/week 20–39 y 80%, awakenings nightly 40–59 y 75%, 60–80 y 70% SABA use ≤2 days/week >2 days/week, Daily Several times per day © Jones &for Bartlett symptom Learning, LLC but not daily and © Jones & Bartlett Learning, LLC NOT FOR controlSALE OR DISTRIBUTION not >1 time/day NOT FOR SALE OR DISTRIBUTION Interference None Minor limitation Some limitation Extreme limitation with normal activity

Lung function Normal FEV1 FEV1 >80% of FEV1 >60% but <80% FEV1 <60% of © Jones & Bartlett Learning, LLC between predicted© Jones & Bartlettof predicted Learning, LLCpredicted exacerbations NOT FOR SALE OR DISTRIBUTION FEVNOT1/FVC normalFOR SALEFEV1/FVC OR reduced DISTRIBUTION 5% FEV1/FVC reduced >5% Risk Exacerbations 0–1/ya >2/ya requiring Consider severity and interval since last exacerbation. oral systemic Frequency and severity may ﬂuctuate over time for patients in any severity corticosteroids © Jones &category. Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR RelativeSALE annualOR DISTRIBUTION risks of exacerbations may be related toNOT FEV1. FOR SALE OR DISTRIBUTION

features determines the clinical presentation and the severity of the Step 4: Preferred: Medium-dose ICS and LABA disease, including variable and recurring symptoms such as cough- Alternative: Medium-dose ICS and LTRA or theophylline or 12, 13 ing, wheezing,© Jones shortness & Bartlett of breath, andLearning, chest tightness. LLC zilueton© Jones & Bartlett Learning, LLC AlthoughNOT asthmaFOR SALEusually presents OR DISTRIBUTION in children, it is common Step 5: Preferred:NOT FORHigh-dose SALE ICS and OR LABA DISTRIBUTION and oral cortico- among persons over the age of 65 and is an important cause of illness steroid and consider omalizumab for patients who have and death among older adults. When asthma does occur in advanced allergies age, the symptoms are similar to those of young adults. However, Step 6: Preferred: High-dose ICS and LABA and oral cortico- asthma can be more dangerous in older adults because they are more steroid and consider omalizumab for patients who have likely to develop respiratory failure even with mild attacks.12–14 © Jones & Bartlett Learning, LLC © Jonesallergies & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION What Is Your Treatment Plan? An important component of this stepwise treatment strategy is reevaluation of treatment within 2 to 6 weeks of diagnosis so Pharmacologic medications can be adjusted. After you determine disease severity, the National Asthma Educa- Nonpharmacologic tion and Prevention Program© Jones (NAEPP) & guidelines Bartlett recommend Learning, a LLC © Jones & Bartlett Learning, LLC stepwise approach to theNOT pharmacologic FOR SALE management OR ofDISTRIBUTION asthma Ñ Follow up in 1 month to developNOT action FOR treatment SALE plan OR based DISTRIBUTION for ages 12 and older.12 on peak flow measurements15 Step 1: Preferred: Short-acting beta-2-agonist (SABA) prn Ñ Evaluate symptom control on routine follow-up using one of Step 2: Preferred: Low-dose inhaled corticosteroids (ICS) the following: Ñ Alternative:© Jones Cromolyn, & Bartlett leukotriene Learning, receptor antagonists LLC (LTRA), Asthma© Jones Therapy &Assessment Bartlett Questionnaire Learning, (https://LLC nedocromil,NOT FOR or theophylline SALE OR DISTRIBUTION evidencebasedpractice.osumc.edu/Documents/NOT FOR SALE OR DISTRIBUTION Guidelines/ATAQChecklist.pdf ) Step 3: Preferred: Low-dose ICS and long-acting beta-2-agonist Ñ (LABA) or medium-dose ICS Asthma Control Questionnaire (http://aafa.org/pdfs/ SWP%20final%20questionnaire.pdf) Alternative: Low-dose ICS and either LTRA, theophylline, or Ñ zileuton Asthma Control Test (http://www.asthmacontrol.com) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 39 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 39 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 40 CHAPTER 3 | Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEEducation/Counseling OR DISTRIBUTION NOT FORA: Moderate SALE persistent OR DISTRIBUTION asthma Tobacco use Ñ Discuss and demonstrate correct device technique. P: Discussed etiology and pathophysiology of asthma, signs of Ñ Discuss importance of annual influenza vaccine. deterioration, and when to contact healthcare provider. Dis- Ñ Provide peak flow meter and instructions to take peak flow cussed the purpose of inhaled SABA, LABA, and inhaled corti- measurement daily × 1 month. © Jones & Bartlett Learning, LLCcosteroid. Start albuterol 1–2© puffs Jones prn for & SOB Bartlett and wheezing Learning, LLC Ñ Smoking cessation: MakeNOT a FORstrong recommendationSALE OR DISTRIBUTION to quit, and 100/50 fluticasone propionate/salmeterolNOT FOR SALE diskus, OR 1 puff DISTRIBUTION discuss motivation to attempt smoking cessation, and offer twice daily. Demonstrated use of inhalers; returned demon- 12 strategies for smoking cessation. stration without difficulty. Emphasized importance of rins- ing mouth after inhaler use to minimize chance of developing SOAP Note candidiasis. Recommended having cat sleep in another room, S: Jennifer© Jones presents & todayBartlett with aLearning, complaint of a LLC chronic cough which she© isJones reluctant & to Bartlettdo. Described Learning, how smoking LLC affects ofNOT more thanFOR 2 months SALE and OR shortness DISTRIBUTION of breath. She has daily asthma. NOTShe would FOR like SALEto try to titrateOR DISTRIBUTIONher cigarette smoking symptoms and awakens with nighttime symptoms 2–3 times down gradually. Plan is to decrease daily cigarettes down to 15 a week. Sometimes the cough produces clear phlegm. She daily within the next month. She is strongly motivated to stop reports wheezing and chest tightness that worsen when she smoking because symptoms are interfering with sleep and abil- goes to the gym. She has stopped going to the gym because ity to exercise. Ordered and demonstrated proper use of peak © Jones & Bartlettof the SOB. Learning, She is trying to LLC cut down her smoking habit; now© Jonesflow & meter.Bartlett Take Learning,daily measurement LLC for 1 month and bring NOT FOR SALEdown toOR 1 pack DISTRIBUTION daily. No other environmental exposures exNOT- FORthese SALE values toOR 1-month DISTRIBUTION follow-up visit. Evaluate symptoms cept her pet cat, which she has slept with nightly for the last 4 and develop asthma action plan at that time. years. She reports her cousin has asthma. Health Promotion Issues O: Vital Signs: BP 104/64, HR 94 (regular), RR 20, T 97.6 EENT: Visual fields and© JonesEOM intact. & BartlettTMs translucent, Learning, gray, LLCÑ Annual influenza vaccine © Jones & Bartlett Learning, LLC light reflex and landmarksNOT FORvisible, SALEno fluid. ORNose: DISTRIBUTION Mucosa Ñ Use nonsteroidal anti-inflammatoryNOT FOR drugs SALE (NSAIDs) OR spar DISTRIBUTION- pink, clear discharge, no polyps. Mouth: No pharyngeal ingly because they may exacerbate symptoms edema, exudates, or lymphadenopathy. No frontal/maxillary sinus tenderness. Negative transillumination. Guidelines to Direct Care Lungs: Resonant to percussion, lung expansion equal. No in- Global Initiative for Asthma. Pocket Guide for Asthma Management crease© Jones in AP/lateral & Bartlett diameter. Learning, Diffuse expiratory LLC wheezes and Prevention© Jones. http://www.ginasthma.org/local/uploads/files/ & Bartlett Learning, LLC bilaterally.NOT FOR No voice SALE sounds OR or tactileDISTRIBUTION fremitus. GINA_Pocket_April20_1.pdf.NOT FOR SALE Accessed OR DISTRIBUTION September 16, 2015. CV: S1, S2 RRR, no murmurs, rubs, or gallops National Heart, Lung, and Blood Institute. Expert Panel Report Abdomen: Nontender, no masses or guarding. BS+ 3: guidelines for the diagnosis and management of asthma. PFTs taken 10 minutes after 2 puffs of albuterol: FEV1/FVC http://www.nhlbi.nih.gov/health-pro/guidelines/current/ <70% of predicted; FEV 56% of predicted asthma-guidelines. Accessed September 16, 2015. © Jones & Bartlett Learning,1 LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Case 4

Mr. Lucas is a 65-year-old ©man Jones complaining & Bartlett of increasing Learning, shortness LLCLungs: No evidence of consolidation© Jones or focal & abnormality, Bartlett fairly Learning, LLC of breath over the last few NOTmonths. FOR He reports SALE that heOR is used DISTRIBUTION to be- diffuse mild end-expiratoryNOT wheezing. FOR Breathing SALE throughOR DISTRIBUTION ing SOB with physical exertion but has started to feel SOB when pursed lips and has a prolonged expiratory phase during performing basic daily activities. He denies fever, sick contact, or quiet breathing.

weight loss. He does report a chronic cough that is occasionally pro- CV: S1 and S2 RRR, faint heart sounds with no murmurs ductive of whitish sputum but has not noticed any recent change in Abdomen: Soft, nontender with good bowel sounds. No bruits the frequency© Jones or character & Bartlett of his cough. Learning, He doesn’t LLCtake any regular © Jones & Bartlett Learning, LLC Extremities: Full range of motion of all extremities. No cyanosis medication.NOT He FOR has a SALE65-pack-year OR history DISTRIBUTION of cigarette smoking. NOT FOR SALE OR DISTRIBUTION or edema

Physical Exam What additional assessments/diagnostics do you need? Vital Signs: BP 138/88, HR 88 (regular), RR 18, T 98.8 What is the differential diagnoses list? © Jones &GEN: Bartlett Thin and Learning, mildly dyspneic LLC © JonesWhat & is Bartlett your working Learning, diagnosis? LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 40 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 40 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 4 41 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEAdditional OR DISTRIBUTION Assessments/Diagnostics Needed NOT FORDescription SALE Findings OR DISTRIBUTION (based on postbronchodilator FEV1) 0 At risk for COPDrisk factors and chronic symptoms ROS but normal spirometry Key indicators for considering a COPD diagnosis include: 1 Mild COPD FEV1/FVC ratio <0.70 Ñ Chronic cough © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FEV1 ≥80% of predicted value Ñ Chronic sputum productionNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 0 Moderate COPD Ñ Repeated episodes of acute bronchitis FEV1/FVC ratio <0.70 Ñ Dyspnea that is progressive, persistent, worse on exercise, FEV1 50% to <80% of predicted value and worse with respiratory infections May have chronic symptoms Ñ History of exposure to risk factors, including tobacco smoke, © Jones & Bartlett Learning, LLC 0 Severe© Jones COPD & Bartlett Learning, LLC occupationalNOT FOR dust SALE and chemicals, OR DISTRIBUTION smoke from home cooking NOT FOR SALE OR DISTRIBUTION and heating fuels FEV1/FVC ratio <70% FEV <30% of predicted value Ñ Three tools helpful for assessing COPD include: 1 May have chronic symptoms Ñ COPD Assessment Test (CAT): Measures health status im- 16 0 Very severe COPD pairment in COPD © Jones & Bartlett Learning, LLC © Jones FEV & Bartlett/FVC ratio <70%Learning, LLC Ñ Clinical COPD Questionnaire (CCQ): Measures clinical 1 NOT FOR SALEcontrol OR in DISTRIBUTION COPD17 NOT FOR FEV SALE1<30% of OR predicted DISTRIBUTION value OR Ñ Modified British Medical Research Council (MMRC) dys- FEV1 <50% of predicted value plus severe chronic symptoms pnea scale: Measures health status and predicts future 2. Chest X-raypulmonary hyperinflation, flattening of the mortality risk18 diaphragm, and increased retrosternal clear space on the later view are all classic findings for COPD. Valuable to exclude Ñ To assess for risk of© exacerbations, Jones & useBartlett the history Learning, of exac- LLC © Jones & Bartlett Learning, LLC alternative diagnoses erbations and spirometry.NOT High-risk FOR SALE patients ORare those DISTRIBUTION with NOT FOR SALE OR DISTRIBUTION two or more exacerbations within the last year, those with an 3. Alpha-1 antitrypsin deficiency screening for alpha-1 antitrypsin deficiency, which is a rare autosomal cause of em- FEV1 <50% of predicted values, or patients with one or more hospitalizations for COPD19 physema in young patients with no smoking history. Not indicated for this patient. Perform when COPD develops in Ñ Assess for comorbid conditionsthese may influence patients of Caucasian descent younger than the age of 45 or mortality© Jones and & hospitalizations Bartlett Learning, and should LLC be evaluated © Jones & Bartlett Learning, LLC with a strong family history of COPD routinely:NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 4. Complete blood count (CBC) to evaluate for elevated hemo- Ñ Cardiovascular diseases globin and hematocrit (H&H) (common in COPD) and for Ñ Osteoporosis elevated white blood cell count due to infection Ñ Respiratory infections 5. Pulse oximetry to evaluate for oxygen saturation and need for © Jones & BartlettÑ Anxiety Learning, and depression LLC © Jonessupplemental & Bartlett oxygen Learning, therapy LLC NOT FOR SALEÑ Diabetes OR DISTRIBUTION NOT 6.FOR Electrocardiogram SALE OR DISTRIBUTION(ECG) to evaluate for right ventricular Ñ Lung cancer hypertrophy Ñ Bronchiectasis Arterial blood gases are not indicated in the primary care setting.

Physical Exam Differential Diagnoses List © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC This patient has some NOTclassic FORfindings, SALE including OR expiratory DISTRIBUTION Asthma NOT FOR SALE OR DISTRIBUTION wheezing, pursed-lip breathing, and a prolonged expiratory phase. Congestive heart failure Other notable findings to look for include an increased anteropos- Bronchiectasis terior (AP) diameter, use of accessory muscles of respiration, hy- Tuberculosis perresonace to percussion, hypoxemia, cyanosis, and signs of right Diffuse panbronchiolitis heart ©failure Jones in advanced & Bartlett cases. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION WorkingNOT Diagnosis FOR SALE COPD OR DISTRIBUTION Routine Labs/Diagnostics 1. Spirometry is required to establish the diagnosis and severity Pathophysiology of disease COPD is a common preventable and treatable disease. COPD 19 © Jones & BartlettGold Staging Learning, System for COPD LLC Severity © Jonesis the third& Bartlett leading cause Learning, of death in LLC the United States and has NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 41 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 41 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 42 CHAPTER 3 | Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

NOT FORcontinued SALE toOR increase DISTRIBUTION in incidence. The burden of this diseaseNOT FORNonpharmacologic SALE OR DISTRIBUTION will likely increase in the future because of continued exposure to Ñ Oxygen therapy: Long-term administration of oxygen (>15 COPD risk factors and the aging population. hours daily) has been shown to increase survival in patients COPD is characterized by persistent airflow limitation involv- with severe resting hypoxemia. ing both small airway disease and parenchymal destruction. In Ñ the small airways, flow limitation© Jones is due & toBartlett airway inflammation, Learning, LLC Ventilatory support: A combination© Jones of noninvasive & Bartlett ventilation Learning, LLC airway fibrosis, luminal NOTplugs, andFOR increased SALE airway OR resistance.DISTRIBUTION with long-term oxygen therapyNOT may FOR be helpful SALE in ORpatients DISTRIBUTION Parenchymal destruction occurs because of loss of alveolar attach- with pronounced daytime hypercapnia. ments and a decrease in elastic recoil.19–21 Ñ Surgery: Surgical treatment options include lung volume reduction surgery and lung transplantation in appropriately What Is Your Treatment Plan? selected patients.19 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC PharmacologicNOT FOR SALE OR DISTRIBUTION Education/CounselingNOT FOR SALE OR DISTRIBUTION Bronchodilators: Education and counseling are important to help prevent exacerbations. Exacerbations negatively affect quality of life, accelerate Ñ Principal agents include beta-2 agonists, anticholinergics, the rate of decline of lung function, are associated with significant theophylline, or combination therapy mortality, and have a high socioeconomic cost.19 © Jones &Ñ Bartlett May be prescribed Learning, as needed LLC or on a schedule to prevent or© Jones & Bartlett Learning, LLC Ñ Smoking cessation has the greatest capacity to influence the reduce symptoms NOT FOR SALE OR DISTRIBUTION NOT FORprogression SALE of OR COPD. DISTRIBUTION Encourage all patients who smoke to Ñ Long-acting agents reduce exacerbations and hospitalization quit. Pharmacotherapy and nicotine replacement increase and improve symptoms long-term smoking abstinence. Use the 5 A’s and 5 R’s. Ñ Combining bronchodilators from different pharmacologic Ñ Encourage regular physical activity. Recommend pulmonary classes instead of increasing the dose of a single agent may rehabilitation program. improve efficacy and© decrease Jones the & risk Bartlett of side effects Learning,19 LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Inhaled corticosteroids: SOAP Note Ñ Scheduled treatment with these medications improves symp- S: Mr. Lucas is a 65-year-old man complaining of increasing short- toms, lung function, and quality of life and reduces frequency ness of breath over the last few months. He recently has noticed of exacerbations in patients with an FEV1 <60% of predicted. increasing SOB while performing basic daily activities. In the 19 past he has had dyspnea on exertion (DOE). He has a chronic Ñ These© Jones drugs may & Bartlettincrease risk Learning, of pneumonia. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION cough thatNOT is occasionally FOR SALE productive OR of DISTRIBUTIONwhitish sputum; no re- Combination therapy: cent change in the character of his cough. He takes no regular Ñ Combining a long-acting beta-2 agonist with an inhaled cor- medication. Significant 65-pack-year smoking history. ticosteroid is more effective in improving lung function and O: Vital Signs: BP 142/86, HR 76, RR 18, afebrile. O2 satura- reducing exacerbations in patients with moderate to very se- tion 94% © Jones & Bartlettvere COPD. Learning, LLC © JonesGEN: & Thin, Bartlett mildly dyspneicLearning, LLC NOT FOR ÑSALE Adding OR a third DISTRIBUTION agent (anticholinergic) to the drug regimenNOT FORHEENT: SALE PERRLA, OR EOMs DISTRIBUTION intact. Normal fundoscopic exam. appears to provide additional benefit. No sinus tenderness on palpation. TMs normal, turbinates Ñ Phosphodiesterase-4 inhibitors are indicated for patients in without redness or bogginess, pharynx without exudates. GOLD 3 and GOLD 4 stages to reduce exacerbations.19 Neck: Supple, no lymphadenopathy, thyroid enlargement, jugular vein distention (JVD), or carotid bruits Theophylline: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Cardiovascular (CV): S and S regular rate and rhythm without Ñ 1 2 Less effective and lessNOT well tolerated FOR SALEthan inhaled OR long-acting DISTRIBUTION murmurs, gallops, or rubs NOT FOR SALE OR DISTRIBUTION bronchodilators; not recommended if those drugs are avail- Resp: No labored breathing. Lungs: Increased AP diameter, no able and affordable. dullness to palpation, decreased breath sounds throughout Ñ Low-dose theophylline reduces exacerbations but doesn’t with mild expiratory wheezing improve postbronchodilator lung function.19 © Jones & Bartlett Learning, LLC Abdomen: Soft,© Jones nontender, & goodBartlett bowel sounds, Learning, no organomegaly LLC Antibiotics:NOT FOR SALE OR DISTRIBUTION Extremities:NOT Dorsalis FOR pedis SALE (DP) ORand posteriorDISTRIBUTION tibial (PT) Ñ Only should be used for treating infectious exacerbations of pulses +2, trace pedal edema COPD and other bacterial infections. CXR: Pulmonary hyperinflation, flattening of the diaphragm Ñ Chronic treatment with systemic corticosteroids should be Pulmonary function test (after bronchodilation with 2 puffs al- avoided because of an unfavorable benefit-to-risk ratio.19 buterol) FEV /FVC ratio 0.60; FEV 60% of predicted value © Jones & Bartlett Learning, LLC © Jones & Bartlett1 Learning, LLC1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 42 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 42 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 5 43 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECBC: H&H OR 16/48, DISTRIBUTION white blood cells (WBCs) 3.8 NOT FORFollow-up: SALE 1 month OR DISTRIBUTION CAT test = 25 Health Promotion Issues MRRC score = 3 Clinical COPD questionnairedeferred until after therapy is Ñ Influenza vaccines yearly Ñ initiated © Jones & Bartlett Learning, LLC Pneumococcal polysaccharide© Jones vaccine is & recommended Bartlett Learning, for LLC COPD patients 65 years and older and for COPD patients A: COPD (moderate, stageNOT 2) FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Tobacco use disorder younger than age 65 with an FEV1 <40% of predicted P: Discussed the nature of COPD. Albuterol, 1–2 puffs q 4–6 hours as needed for shortness of breath. Fluticasone propio- Guidelines to Direct Care nate/salmeterol inhaled 250/50, 1 puff inhaled every 12 hours. Global Initiative for Chronic Obstructive Lung Disease. Demonstrated© Jones &proper Bartlett use of inhalers.Learning, Returned LLC demonstra- http://www.goldcopd.org/.© Jones & Bartlett Accessed Learning, September 16, LLC 2015. tion without difficulty. Referral for pulmonary rehabilitation NOT FOR SALE OR DISTRIBUTION Centers forNOT Disease FOR Control SALE and Prevention.OR DISTRIBUTION Prevention and exercise program. Discussed importance of risk reduction, control of seasonal influenza with vaccines: recommenda- including smoking cessation, and offered medication to assist tions of the Advisory Committee on Immunization Practices with smoking cessation. Declines at this time but has strong (ACIP)United States, 2014–15 influenza season. . motivation to quit. Wants to try slow taper of cigarettes. Avoid MMWR 2014;63(32):691–697. http://www.cdc.gov/mmwr/preview/ © Jones & Bartlettvigorous outdoor Learning, exertion LLC or stay inside on high-pollution© Jones & Bartlett Learning, LLC mmwrhtml/mm6332a3.htm. Accessed September 16, 2015. NOT FOR SALEdays. WillOR evaluate DISTRIBUTION for home oxygen on a routine basis. DisNOT- FOR SALE OR DISTRIBUTION cussed strategies for minimizing dyspnea, including pursed-lip breathing. Influenza and pneumococcal vaccine today.

Mr. Roos is a 57-year-old man who comes to the office complaining use of immunosuppressing drugs; use of antimicrobials within the of fever and a cough. He states that he felt completely healthy 4 days previous 3 months (in which case an alternative from a different ago, but on the following day started feeling feverish and coughed class should be selected); or other risks for drug-resistant Strepto- up yellowish-green© Jones &phlegm Bartlett the next Learning, morning. His symptomsLLC have coccus pneumoniae© Jones (DRSP) & infection. Bartlett Learning, LLC progressivelyNOT FORworsened. SALE He also OR mentions DISTRIBUTION that his chest hurts on NOT FOR SALE OR DISTRIBUTION the right side when he takes a deep breath. He reports that his wife Physical Exam was sick with milder but similar symptoms a week or two ago. Ñ The physical exam should include a respiratory, cardiovascu- PMH: Includes hypertension and arthritis. His medications in- lar, abdominal, skin, and mental health assessment clude metoprolol and celecoxib. He smokes roughly a pack Ñ Physical exam for this patient revealed decreased breath © Jones & Bartlettof cigarettes Learning, per day but does LLC not drink alcohol or use other© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORsounds, SALE dullness OR to DISTRIBUTIONpercussion, and increased tactile fremitus drugs. No drug allergies. in the right lower lobe. All other systems were within normal limits Physical Exam Ñ Assess for criteria for clinical stability including:22 Vital Signs: BP 128/86, HR 101 (regular), RR 18, T 37.4°C Ñ Temp ≤37.8°C GEN: Appears mildly tachypneic,© Jones but & is Bartlettnot in distress Learning, LLCÑ HR ≤100 bpm © Jones & Bartlett Learning, LLC What additional assessments/diagnosticsNOT FOR SALE do ORyou need? DISTRIBUTIONÑ RR ≤24 breaths/min NOT FOR SALE OR DISTRIBUTION What is the differential diagnoses list? Ñ Systolic blood pressure (SBP) ≥90 mm Hg What is your working diagnosis? Ñ Arterial oxygen sat ≥90% Ñ Ability to maintain oral intake Additional© Jones & Assessments/Diagnostics Bartlett Learning, LLC Needed Ñ Normal© Jones mental status & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Ñ Assess forNOT severity FOR of illness SALE OR DISTRIBUTION ROS Ñ CURB-65 criteria help determine hospital admission Evaluate for presence of comorbidities (to direct antibiotic tx), decision (confusion, uremia, respiratory rate, low blood including chronic heart, lung, liver, or renal disease; DM; alcohol- pressure, age 65 or greater) (Curb-65 Pneumonia Severity ism; malignancies; asplenia; immunosuppressing conditions or Score).23 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 43 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 43 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 44 CHAPTER 3 | Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEÑ Pneumonia OR DISTRIBUTION Severity Index (PSI) can be used to identifyNOT 5.FOR Class SALE 5: Points OR >130: DISTRIBUTION Mortality 29.2% (high risk) patients with CAP who may be candidates for outpatient treatment versus inpatient treatment (Pneumonia Sever- Interpretation 24 ity Index Calculator). 1. Classes 1–2: Outpatient management 2. Class 3: Consider short observation hospital stay General © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 3. Classes 4–5: Inpatient management The information below (general,NOT FOR PMH, SALE physical OR exam, DISTRIBUTION and lab NOT FOR SALE OR DISTRIBUTION and radiology findings) all relate to the pneumonia severity index. Additional Diagnostics Needed 1. Age in years: Add 1 point per year CBC (WBC = 14,900, neutrophils = 87%, platelets = 310,000/ 2. Gender: Subtract 10 points for women uL, Hgb = 16, Hct = 48) 3. Nursing© Jones home &resident: Bartlett Add 10Learning, points LLC Basic metabolic© Jones panel (BMP) & Bartlett (Na = 137, Learning, K = 4.1, BUN LLC = 15, Cr = 1.0, BG = 148) PastNOT Medical FOR SALE History OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pulse oximetry (98%) 1. Cancer: Add 30 points Chest X-ray (consolidation of right midlobe. No pleural effu- 2. Liver disease: Add 20 points sion noted) 3. © Jones & BartlettCHF: Add Learning, 10 points LLC © JonesPulmonary & Bartlett function Learning, tests (PFTs) (not LLC really helpful in this situ- 4. ation, i.e., we expect them to be abnormal) NOT FOR SALECVA: AddOR 10 DISTRIBUTION points NOT FOR SALE OR DISTRIBUTION 5. Chronic kidney disease: Add 10 points Sputum/blood cultures: The overall yield and infrequent positive impact on clinical care argue against the routine use of Examination Findings blood and sputum cultures. Therefore, the guidelines suggest empirical treatment for patients in the outpatient setting (as 1. Altered level of consciousness:© Jones Add & 20 Bartlett points Learning, LLClong as you have risk stratified© appropriately).Jones & Bartlett Learning, LLC 2. Breathing rate >30 rpm:NOT Add FOR 20 points SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3. Systolic BP <90 mm Hg: Add 20 points Differential Diagnoses List 4. Temperature not 95–104°F (35–40°C): Add 15 points Community-acquired pneumonia (CAP) 5. Heart rate >125 bpm: Add 10 points COPD Labs© Jones & Bartlett Learning, LLC Lung abscess© Jones & Bartlett Learning, LLC Pulmonary embolism ArterialNOT blood FOR gas (ABG): SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Congestive heart failure (CHF) 1. Arterial pH <7.35: Add 30 points Neoplasms 2. PaO2 <60 mm Hg (<90% O2 sat): Add 10 points Sarcoidosis Keep in mind that arterial blood gases (ABGs) are not usually © Jones &ordered Bartlett in the primaryLearning, care setting. LLC This parameter limits the abil©- JonesWorking & Bartlett Diagnosis Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ity to use this scoring system in the office. However, its use is help- Community-acquired pneumonia ful for patients presenting to the emergency department (ED) Tobacco use disorder where an ABG can be obtained. Labs: Serum chemistry: Pathophysiology 1. Serum sodium <130© mEq/L: Jones Add & 20 Bartlettpoints Learning, LLCCAP is one of the most common© infectious Jones diseases. & Bartlett Streptococcus Learning, LLC 2. Blood urea nitrogen NOT(BUN) FOR>64 mg/dL: SALE Add OR 20 points DISTRIBUTIONpneumoniae, Haemophilus influenzaeNOT, and FOR Moraxella SALE catarrhalis OR areDISTRIBUTION 3. Serum glucose >250 mg/dL: Add 10 points the pathogens that account for approximately 85% of CAP. CAP 4. Blood counthematocrit <30%: Add 10 points usually occurs as a result of inhalation or aspiration of the patho- gen into a lung segment or lobe; it may also occur from a distant 5. Chest X-raypleural effusion: Add 10 points source or from bacteremia. Morbidity and mortality are highest in 25 Scoring© Jones & Bartlett Learning, LLC elderly patients© Jonesand immunocompromised & Bartlett Learning, hosts. LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Class 1: Points 0: Mortality 0.1% (low risk) What Is Your Treatment Plan? 2. Class 2: Points <70: Mortality 0.6% (low risk) CURB-65 score indicates that this patient can be treated in the 3. Class 3: Points 71–90: Mortality 2.8% (low risk) outpatient setting. PSI score was not calculated because of un- 4. Class 4: Points 91–130: Mortality 8.2% (moderate risk) © Jones & Bartlett Learning, LLC © Jonesavailability & Bartlett of ABGs. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 44 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 44 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 5 45 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Pharmacologic NOT FORÑ For SALEsmokers, ORpatients DISTRIBUTION must have repeat CXR in 6 months to NOT FOR SALE OR DISTRIBUTION 25 Basic concepts: verify that pneumonia was not caused by underlying mass. Ñ Patients with pneumonia should be treated with antibiotics SOAP Note for at least 5 days. S: Mr. Roos is a 57-year-old man who reports fever and productive Ñ Antibiotics should not© beJones stopped & until Bartlett the patient Learning, has been LLCsputum, which began 3 days© ago. Jones His symptoms & Bartlett have progres Learning,- LLC afebrile for at least 48NOT to 72 hours.FOR SALE OR DISTRIBUTIONsively worsened. He deniesNOT SOB, FORDOE, palpitations,SALE OR light DISTRIBUTION- Ñ The most common causes of CAP in outpatients are S. pneu- headedness, or headaches. He reports that his chest hurts on the moniae, Mycoplasma pneumoniae, and H. influenzae; patient right side when he takes a deep breath. He is currently able to history, clinical findings, and epidemiology may suggest a drink fluids without difficulty, but his appetite is poor. He denies cause that could alter therapy. See Table 3-2. nausea, vomiting, diarrhea, or abdominal pain. His wife was sick © Jones & Bartlett Learning, LLC with milder© Jonessymptoms & a weekBartlett or two Learning,ago but got better LLC with- NonpharmacologicNOT FOR SALE OR DISTRIBUTION out treatment.NOT He FOR smokes SALE 1 pack OR of cigarettes DISTRIBUTION daily but does Ñ Drink fluids to avoid dehydration. not drink alcohol. He has not taken any antibiotics for the last se veral years. PMH is significant for HTN and arthritis. Had in- Ñ Take deep breaths and cough hourly. fluenza vaccine this year but never got pneumococcal vaccine. Ñ Use a humidifier to make air warm and moist. O: Vital Signs: T 37.4°C, BP 128/86, RR 18, HR 101 (regular), © Jones &Ñ Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Rest. pulse oximetry 98% Ñ 25 NOT FOR SALE Take acetaminophen, OR DISTRIBUTION ibuprofen, or naproxen for fever or pain.NOT FORGEN: AppearsSALE mildly OR DISTRIBUTIONtachypneic, but is not in distress Education/Counseling Skin: Warm and dry, good skin turgor HEENT: No sinus tenderness. PERRLA, EOMs intact. Normal Ñ Emphasize importance of taking the antibiotic until gone, fundoscopic exam. TMs normal, turbinates mildly reddened, even if symptoms improve. © Jones & Bartlett Learning, LLCbut no discharge. Pharynx ©without Jones exudate, & Bartlett cobblestoning, Learning, LLC Ñ Call back if you developNOT newFOR or SALEworsening OR shortness DISTRIBUTION of or enlargement. Neck: Supple,NOT no thyroid FOR enlargement,SALE OR JVD, DISTRIBUTION breath, chest pain, or confusion or cough up bloody or rust- or carotid bruits. No lymphadenopathy colored mucus.

TABLE 3-2 Clinical Characteristics and Possible Antibiotic Choices © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Patient Characteristics Outpatient Oral Antibiotic Regimen NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Previously healthy; no risk factors for drug-resistant S. pneumoniae Macrolide • Azithromycin • Clarithromycin • Erythromycin © Jones & Bartlett Learning, LLC © Jones & BartlettOR Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR• Doxycycline DISTRIBUTION Comorbidity or risk factor for drug-resistant S. pneumoniae, including: Macrolide PLUS beta-lactam: • Use of a broad spectrum antibiotic in the previous 3 months • High-dose amoxicillin • Age older than 65 years • Alternative to macrolide-doxycycline • Alcoholism © Jones & Bartlett Learning, LLC Alternative to© oral Jones beta-lactams: & Bartlett Learning, LLC • Chronic disease (e.g., heart, lung, liver, or kidney disease; diabetes) • PO cefpodoxime or cefuroxime NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Cancer IM ceftriaxone • Asplenia OR • Exposure to a child in day care • Respiratory fluoroquinolone: • Immunosuppression • Moxifloxacin • Levofloxacin Note:© IfJones the patient & Bartlett has received Learning, an antibiotic LLC within the previous © Jones & Bartlett Learning, LLC 3 months,NOT pickFOR an SALE option fromOR DISTRIBUTIONa different class. NOT FOR• Gemifloxacin SALE OR DISTRIBUTION Lives in a region with >25% or higher rate of infection with high-level As above (MIC ≥16 mcg/mL) macrolide-resistant S. pneumoniae Source: Courtesy of Prescriber’s Letter. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 45 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 45 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 46 CHAPTER 3 | Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECV: HR RRROR without DISTRIBUTION murmurs, gallops, or rubs NOT FORHTN: ContinueSALE OR metoprolol. DISTRIBUTION Encouraged heart healthy lifestyle. Resp: No labored breathing. Decreased breath sounds, dullness Tobacco use: Advised regarding the importance of smoking ces- to percussion, and increased tactile fremitus in the right sation. Stressed that smoking may contribute to development lower lobe (RLL). Mild crackles in the RLL without wheezes of pneumonia. Patient is willing to discuss smoking cessation or egophony strategies at follow-up visit. Handouts provided on possible Abdomen: Soft, nontender,© Jones good bowel & sounds, Bartlett no organomegaly Learning, LLCsmoking cessation interventions.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Extremities: DP and PT pulses +2, trace pedal edema Health Promotion Issues Mental Status: Awake and oriented × 3 Ñ Recommend yearly influenza vaccine. Labs: CBC (WBC = 14,900, neutrophils = 87%, platelets = Ñ Recommend pneumococcal vaccine now. 310,000/uL, Hgb = 16, Hct = 48) Ñ Wash hands frequently and practice good hygiene. BMP© (Na Jones = 137, &K = Bartlett 4.1, BUN = Learning, 15, Cr = 1.0, BG LLC = 148) © Jones & Bartlett Learning, LLC Ñ CXR:NOT Consolidation FOR SALE of right midlobe.OR DISTRIBUTION No pleural effusion noted StronglyNOT recommend FOR smoking SALE cessation OR DISTRIBUTION and offer treatment options. CURB-65 Pneumonia Severity Score = 1 point (age) low risk A: CAP: Clinically stable Guidelines to Direct Care HTN: At JNC 8 goals © Jones &Tobacco Bartlett use: PoorLearning, motivation LLC to try quit attempt at this time © JonesMandell & LA, Bartlett Wunderink Learning, RG, Anzueto LLC A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus guide- P: CAP: Azithromycin 500 mg daily × 3 days. Discussed impor- NOT FOR SALE OR DISTRIBUTION NOTlines FOR on theSALE management OR DISTRIBUTION of community-acquired pneumonia in tance of taking antibiotic until gone. Drink fluids, rest, take adults. Clin Infect Dis. 2007;44:S27–72. deep breaths and cough hourly, use humidifier. May use acetaminophen for fever or pain. Pneumococcal vaccine today. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION REFERENCES 1. World Health Organization. WHO recommendations on the use 10. Braman SS. Chronic cough due to acute bronchitis: ACCP evi- of rapid testing for influenza diagnosis. http://www.who.int/ dence-based clinical practice guidelines. Chest. 2006;129(I suppl): influenza/resources/documents/RapidTestInfluenza_WebVersion 95S–103S. http://www.ncbi.nlm.nih.gov/pubmed/16428698 .pdf.© AccessedJones September & Bartlett 4, 2014. Learning, LLC 11. Matthys H,© EisebittJones R, Seith& Bartlett B, Heger M. Learning, Efficacy and safety LLC of an 2. HarperNOT SA, FOR Bradley SALE JS, Englund OR JA, DISTRIBUTION et al. Expert Panel of the Infec- extract ofNOT Pelargonium FOR sidoides SALE (EPs 7630) OR in DISTRIBUTION adults with acute bron- tious Diseases Society of America: Seasonal influenza in adults and chitis. A randomized, double-blind, place-controlled trial. Phytomed- childrendiagnosis, treatment, chemoprophylaxis and institutional icine. 2003;10(suppl 4):7–17. outbreak management: clinical practice guideline. Clin Infect Dis. 12. National Heart, Lung, and Blood Institute. Guidelines for the diag- 2009;48(8):1003–1032. Accessed September 4, 2014. nosis and management of asthma (EPR-3). http://www.nhlbi.nih 3. Centers for Disease Control and Prevention. Guidance for clini- .gov/health-pro/guidelines/current/asthma-guidelines. Accessed © Jones & Bartlettcians on the Learning, use of rapid influenza LLC diagnostic tests. http://www© JonesSeptember & Bartlett 4, 2014. Learning, LLC NOT FOR SALE.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm. OR DISTRIBUTION NOT 13. FOR US Census SALE Bureau. OR 2008 DISTRIBUTION national population projections: percent Accessed September 4, 2014. distribution of the projected population by selected age groups and 4. Lab Tests Online. Influenza tests. http://labtestsonline.org/ sex for the United States: 2010 to 2050. https://www.census.gov/ understanding/analytes/flu/. Accessed September 4, 2014. population/projections/data/national/2008/summarytables.html. 5. Erlikh IV, Abraham S, Kondamudi VK. Management of influenza. Accessed September 4, 2014. Am Fam Physician. 2010;82(9):1087–1095.© Jones & Bartlett Learning, LLC14. Older–Adults and Asthma ©https://www.aafa.org/display.cfm?id= Jones & Bartlett Learning, LLC 6. Centers for Disease ControlNOT and FOR Prevention. SALE Vaccine OR recommenda DISTRIBUTION- 8&sub=17&cont=173. Accessed NOTSeptember FOR 30, 2015. SALE OR DISTRIBUTION tions of the ACIP. http://www.cdc.gov/vaccines/hcp/acip-recs/ 15. National Heart, Lung, and Blood Institute. Asthma action plan. recs-by-date.html. Accessed September 4, 2014. http://www.nhlbi.nih.gov/health/resources/lung/asthma-action- 7. Centers for Disease Control and Prevention. Flu treatment and what plan-html. Accessed September 4, 2014. to do if you get sick. http://www.cdc.gov/flu/faq/what-to-do.htm. 16. COPD Assessment Test. COPD assessment test. http://catestonline Accessed September 4, 2014. .org. Accessed September 4, 2014. 8. Wenzel© Jones RP, Fowler & AA.Bartlett Clinical practiceacute Learning, bronchitis. LLC N Engl J 17. CCQ. Clinical© Jones COPD questionnaire.& Bartlett http://www.ccq.nl. Learning, LLCAccessed MedNOT. 2006;355(20):2125–2130. FOR SALE OR DISTRIBUTION SeptemberNOT 4, 2014. FOR SALE OR DISTRIBUTION 9. Albert RH. Diagnosis and treatment of acute bronchitis. Am Fam 18. Spiromics. Modified Medical Research Council dyspnea scale Physician. 2010;82(11):1345–1350. (mMRC questionnaire). http://www.cscc.unc.edu/spir/public/

9781284065800_CH03_033_048.indd 46 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 46 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services References 47 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEUNLICOMMMRCModifiedMedicalResearchCouncilDyspnea OR DISTRIBUTION NOT FORon the SALE management OR ofDISTRIBUTION community-acquired pneumonia in adults. Scale08252011.pdf. Accessed September 4, 2014. Clin Infect Dis. 2007;44(suppl 2):S27–72. https://www.thoracic.org/ 19. Global Initiative for Chronic Obstructive Lung Disease. Home page. statements/resources/mtpi/idsaats-cap.pdf. Accessed September 4, http://www.goldcopd.org. Accessed September 4, 2014. 2014. 20. Miniño AM, Xu J, Kochanek KD; Division of Vital Statistics. Deaths: 23. Medscape. CURB-65 pneumonia severity score. http://reference preliminary data for 2008.© Jones Natl Vital & Stat Bartlett Rep. 2010;59(2):1–52. Learning, LLC.medscape.com/calculator/curb-65-pneumonia-severity-score.© Jones & Bartlett Learning, LLC http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_02.pdf. Accessed September 4, 2014. Accessed September 4, NOT2014. FOR SALE OR DISTRIBUTION24. The Ohio State University NOTCollege FORof Medicine. SALE Pneumonia OR DISTRIBUTION 21. Murphy SL, Xu J, Kochanek KD; Division of Vital Statistics. Deaths: Severity Index (PSI) calculator. http://internalmedicine.osu.edu/ preliminary data for 2010. Natl Vital Stat Rep. 2012;60(4):1–51. pulmonary/cap/10849.cfm. Accessed September 4, 2014. http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. 25. Cunha BA. Community-acquired pneumonia. Medscape. 2014. Accessed September 4, 2014. http://emedicine.medscape.com/article/234240-overview#a1. 22. Mandell© Jones LA, Wunderink & Bartlett RG, Anzueto Learning, A, et al. Infectious LLC Diseases Accessed ©September Jones 4, 2014. & Bartlett Learning, LLC SocietyNOT of America/AmericanFOR SALE OR Thoracic DISTRIBUTION Society consensus guidelines NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 47 DESIGN SERVICES OF 13/01/16 2:18 PM # 159813 Cust: JBL Au: Thanavaro Pg. No. 47 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH03_033_048.indd 48 13/01/16 2:18 PM