Critical Pathway: Idiopathic Pulmonary Fibrosis Essay

2568 words - 10 pages

Mr. B is a 65 year old Caucasian male, presenting in the ER with complaints of shortness of breath, and non-productive cough for the past 8 months. He states the shortness of breath worsens with activity and frequent “coughing spells”.
Mr. B has been treated for Pneumonia and Bronchitis over the past 8 months with oral antibiotics and steroids. Mr. B noticed slight improvement of symptoms while on medication; however, the symptoms never resolved, and seem to be progressively worsening.
Mr. B is growing concerned because he has unintentionally lost weight, he tires easily, and he is unable to preach entire sermons without getting “out of breath”. Upon examination, Velcro-like rales are auscultated in bilateral better to use after lungs.lower lungs bilaterally. When talking, the patient is noted to have rapid, shallow breathing. Slight clubbing of the fingers noted. Initial vital signs were (bold indicates abnormal values):
Height- 5 ft 8 in
Weight- 170 lbs
Blood pressure- 122/78
Pulse- 100
Respirations- 28
Oxygen Saturation- 90%
Temperature- 97.6 (oral)
Blood was drawn for routine laboratory tests, and no abnormal values were noted:no ABGs ?
Comprehensive Metabolic Panel
Potassium- 3.3 low 3.5-5.5 mEq/L not addressed in paper
Sodium- 137 135-148 mEq/L
Chloride- 102 96-112 mEq/L
Carbon Dioxide- 34 21-34 mEq/L
Glucose- 73 65-99 mg/dL
Blood Urea Nitrogen- 15 8-25 mg/dL
Creatinine- 0.9 0.6-1.5 mg/dL
Calcium- 8.3 8.0-11 mg/dL
Magnesium- 1.7 1.5-2.5 mg/dL
Phosphorous- 3.3 2.2-4.8 mg/dL
Albumin- 4.3 3.5-5.0 gm/dL
AST- 13 7-21 U/L
ALT- 11 0-30 U/L
Complete Blood Count
RBC- 4.8 4.2-5.6 M/L
WBC- 8 3.8-11.0 K/mm3
Hematocrit- 42 39-54%
Hemoglobin- 16 14-18 g/dL
Platelets- 270 150-450 U/L
MCH- 31.2 27-35 pg
MCHC 36.1 31-37%
MCV- 84 78-98 fL
Chest X-Ray revealed honeycombing and decreased lung volume. Chest CT revealed honeycombing, traction bronchiectasis, and subpleural patchy opacities. No obstructive defect is identified by pulmonary function tests; however, a notable restrictive defect is uncovered.
I. Precipitating Factors
Mr. B was able to provide information regarding his medical history. He has worked as a fulltime preacher for the past 20 years, and before that he worked as a farmer with the family business. Mr. B states that because of a deep love for farming, he has continued to work whenever he has the opportunity.
The patient reports a past medical history of mild gastroesophageal reflux disease (GERD), no past surgical history, and no regular home medications. The patient has never used illegal drugs or alcohol. He has a history of smoking for 25 years; however, he quit smoking 15 years ago.
Mr. B reports a family history of coronary heart disease (father), rheumatoid arthritis (mother), cervical cancer (sister), and an unknown lung disease (sister); Mr. B knows his sister does not have COPD, but he can’t remember the specific disease name.

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