Case Study: A 38-year-old artist has smoked since she was 18 years old

Case Study Template

Name: Not Provided
Week of Class (1-8): Not Specified
Body System Focus Area: Pulmonary and Cardiovascular
Case Study: A 38-year-old artist has smoked since she was 18 years old. She has noticed a mild, occasionally productive cough for the past few months. On a recent trip to the mountains, she developed shortness of breath that caused her to be nauseated. She has had no fever or chills. Her medical history includes hypertension for which she is using lisinopril, metoprolol, and hydrochlorothiazide.

Questions

1. What is the client’s chief complaint?
   The client’s primary concern is a mild, occasionally productive cough persisting for several months, accompanied by shortness of breath severe enough to cause nausea during a recent mountain trip.
2. What questions would you ask the client?
   • HPI (History of Present Illness): How long has the cough been present, and has it worsened over time? Is the cough worse at night or with activity? What does the sputum look like (color, consistency)? When did the shortness of breath begin, and what activities trigger it? How often does nausea occur with the shortness of breath?
   • ROS (Review of Systems): Any chest pain, wheezing, or tightness? Any recent weight loss, fatigue, or night sweats? Any swelling in the legs or ankles?
   • Medical/Surgical/Psych History: Any past lung conditions like asthma or bronchitis? Any surgeries or mental health diagnoses?
   • Family History: Any family history of lung disease, heart disease, or cancer?
   • Other: How many cigarettes per day, and for how many years? Any exposure to secondhand smoke, pollutants, or allergens? Any recent travel besides the mountain trip?
3. What physical examinations would you include?

   Body System	Include? ( or -)	Notes
   General survey		Assess appearance, weight, signs of distress
   HEENT		Check for nasal congestion, throat irritation, or cyanosis
   Cardiovascular		Auscultate heart sounds (stethoscope to actual skin)
   Peripheral Vascular	–	Not indicated based on current data
   Breasts	–	Not indicated
   Lymphatic		Palpate for lymphadenopathy in neck, axillae
   Pulmonary		Auscultate lung sounds (stethoscope to actual skin) – anterior/posterior
   Gastrointestinal/Abdominal	–	Not indicated
   Genitourinary/Pregnancy	–	Not indicated
   Integumentary		Check for cyanosis or clubbing of fingers
   Musculoskeletal	–	Not indicated
   Neurological	–	Not indicated

4. What are pertinent positive physical assessment findings?
   Information provided is limited, but the client’s history suggests a productive cough and shortness of breath with exertion. Potential findings on exam might include wheezing, diminished breath sounds, or prolonged expiration due to her smoking history (assumed based on symptoms).
5. What are the pertinent negative physical assessment findings?
   No fever or chills reported, suggesting the absence of an acute infectious process like pneumonia. Nausea occurred with shortness of breath but no vomiting or abdominal pain noted.
6. What are at least 3 differential diagnoses?
   • Chronic Obstructive Pulmonary Disease (COPD): Likely due to 20-year smoking history and symptoms of cough and dyspnea (D’Cruz et al., 2021).
   • Asthma: Possible if wheezing or reversible airway obstruction is found, though less likely without a history of atopy.
   • High-Altitude Pulmonary Edema (HAPE): Could explain shortness of breath and nausea during the mountain trip, though symptoms resolved afterward, making it less probable as a chronic issue.
7. What is your primary diagnosis?
   Chronic Obstructive Pulmonary Disease (COPD) appears most consistent with the client’s long-term smoking, chronic cough, and exertional dyspnea. The mountain trip likely exacerbated underlying airway obstruction.
8. What is your treatment plan?
   • Diagnostic Procedures: Spirometry to confirm airflow limitation (FEV1/FVC < 0.7 post-bronchodilator). Chest X-ray to rule out other lung pathology.
   • Labs: Complete blood count (CBC) to check for infection or polycythemia; arterial blood gas if hypoxia is suspected.
   • Client Education: Smoking cessation is critical—discuss benefits like improved lung function and reduced symptom progression. Recommend exercise and a healthy diet to support overall health.
   • Pharmacotherapy: Start with a short-acting bronchodilator (e.g., albuterol) for symptom relief. If spirometry confirms COPD, consider a long-acting bronchodilator (e.g., tiotropium) (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2023).
   • Health Promotion: Annual flu vaccine and pneumococcal vaccine to prevent respiratory infections.
   • Follow-Up: Reassess in 4-6 weeks after initiating treatment and smoking cessation efforts.

References

D’Cruz, R. F., Murphy, P. B., & Kaltsakas, G. (2021). COPD: The role of exacerbations in disease progression. Chest, 160(5), 1720-1729. https://doi.org/10.1016/j.chest.2021.06.045

Global Initiative for Chronic Obstructive Lung Disease. (2023). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report. https://goldcopd.org/2023-gold-report-2/