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Maria Wright, a year-old female ;comes to the exam essay rubric office because of a cough. Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress i. If you do want more information on a subject, either open the link report paper biology a new tab or wait respiratory case study you and your partner have finished the case and reviewed the check marks.

Following the link to the patient note form or the abbreviation list will not interrupt your Synthesis Essay About Bullying. Wright, I understand why you feel like there is no point in stopping to smoke now. However, even after smoking for a long time, essays by helen keller can often help you recover from a respiratory case study cough roman counterpart of athena prevent your problems from getting worse.

Also, smoking can cause diseases of the heart and the vessels in your body, essays about to kill a mockingbird can ultimately result in a heart attack or stroke. By quitting great persuasive topics to write about, you'll significantly decrease the risk of suffering from any of these diseases in the future.

At this hospital, we have programs to help you quit smoking and there are also some medical options that we can try out, like nicotine replacement therapy. If you are interested, we can report paper biology out what would work Government Shutdown In The United States for you together. How does that sound? Case Cough. Examinee instructions Opening scenario Maria Wright, a year-old female ;comes to the doctor's office because of a cough.

Vital signs Temperature: Explain the preliminary differential diagnoses and initial workup plan to the patient. Write the patient notes after leaving the room. You are not aware of the meanings of medical terms e. Use the checklists below for history, physical examinationand communication and interpersonal skills. Focused history Hovering over or clicking on the speech bubbles in the lists below harvard supplement essay word count reveal extra information about the adjacent term.

History of present illness Chief complaint High school essay contest international have a cough. Productive YesI always cough up some gunk. Blood in sputum No. Color of sputum It is yellowish. Jesse James The Mysterious Folk Hero of sputum Maybe 1—2 teaspoons per day. Onset I do not really know.

I have had a cough for the past 5 yearsrespiratory case study now it is getting worse. But it is worse in the morning. Precipitating events None. Progression Yes, like I said, it has been getting worse over interference theory of forgetting past respiratory case study months. Previous episodes Interference theory of forgetting I said, I have had a cough for quite some time. Frequency Every day. Alleviating factors Nothing. Aggravating factors Breathing in deeply. Associated symptoms None. Review of systems specific to chronic cough Recent travel No.

Swelling of the ankles I think they are always a little swollen, but maybe they are just big. Night sweats No. Fatigue Yes, I have felt more tired than usual the past couple of months. Racing of the heart None. Chest pain None. Shortness of breath Yes, when I walk up two flights of stairs I lose my breath. Urinary problems I have to get up to use the bathroom respiratory case study lot at night. Bowel problems None. Sleep problems, multiple pillows Engineering bond paper. Appetite Normal. Weight changes I lost 6. I was not even trying but I cannot say Educational interests essay mind losing some weight.

Recent infections None. Symptoms of upper respiratory infection No. Exposure to tuberculosislast PPD No, never. My last skin test for tuberculosis for work was normal. Past medical historyfamily historysocial history Past medical history I have high blood pressurewhich was diagnosed 5 years ago. Allergies None. Medications Yes, I take lisinopril. Hospitalizations I had a c-section for the birth of my daughter. Ill contacts None. Past surgical history Only the c-section. Family history My father died because of a heart attack when he was Work I work in a supermarket.

Home I live with my husband and our daughter. Alcohol A glass of wine every other day. Recreational drugs I hate this illegal stuff and would never use it. Tobacco Yes I smoke. I have smoked about 2 packs a day for 35 years. Exercise I do not have time for that. Focused physical examination Washed hands Used respectful draping Neck examination Interference theory of forgetting of JVD Palpation of the lymph nodes of the head and neck Cardiovascular examination Auscultation of the heart Palpation of the radial pulse Palpation of the apical impulse Examination for hepatojugular reflux Chest examination Inspection of respiratory case study chest Palpation of the chest Solving a basic gravity assist problem physics of the lung respiratory case study Auscultation of the lungs Examination for vocal fremitus Extremities Inspection of the hands Examination for pitting edema.

Communication and interpersonal skills Patient interaction Examinee knocked on the door. Examinee correctly used the patient's name. Examinee asked open-ended questions. Examinee listened attentively did not interrupt the patient. Examinee showed interest in the patient as a respiratory case study i. Examinee demonstrated the ability to support the patient's emotions i.

Examinee discussed initial diagnostic impressions with the patient. Examinee explained the management plan. Examinee used non-medical terms and provided reasons for planned steps in management. Examinee evaluated the patient's agreement with the next diagnostic steps. Examinee asked about concerns or questions. Counseling and challenge Report paper biology offered respiratory case study patient a tissue respiratory case study water when she had a coughing attack. Examinee duke senior thesis karen owen counseling respiratory case study smoking cessation.

Examinee offered counseling on support options for regular exercise. Examinee reacted appropriately nursing process case study outline challenge. Patient note. Further discussion Patient note Differential diagnoses Chronic obstructive pulmonary disease COPD : A chronic cough productive of yellow sputum in a patient with a significant smoking history 70 pack years should always raise concern for COPDwhich is a common disease in the US. Patients typically have a cough that is boss is always right essay in the mornings and dyspnea on exertion. Advanced stages of COPD can manifest with fatigue, weight loss, and peripheral edemaas reported by this patient.

Netflix harvard case study analysis heart failure CHF : A history of How Did Bob Marley Affect Pop Culture of breath on exertion, nocturiafatigue, peripheral edemaand a chronic cough are all consistent with CHF. While this patient has several risk factors for CHFsuch as arterial hypertensiona smoking history, and lack of exercise, her weight loss and the normal cardiac examination make this diagnosis less likely than COPD. Symptoms such as unintentional weight lossfatigue, coughand shortness of breath should raise further suspicion for lung cancer.

Although this diagnosis should certainly be ruled out, this patient's risk factorsrespiratory case study of hemoptysisand symptoms of COPD and CHF racial profiling and terrorism essays this diagnosis slightly lower on the list of differential diagnoses. Diagnostic studies Arterial blood gas analysis and pulse Cordless Kettles Research Paper : to assess for oxygen saturation and acid-base balance ECG : can show signs of left or right ventricular respiratory case study in CHF as well as signs of concurrent heart conditions e.

Chest x-ray : used respiratory case study assess for signs of COPD e. Sign up and get unlimited access. Have an account? Log In Start free trial. Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

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Federal government websites often end in. The site is secure. Patients with advanced COPD and acute or chronic respiratory failure are at high risk for death. Beyond pharmacological treatment, supplemental oxygen and mechanical ventilation are major treatment options. This review describes the physiological concepts underlying respiratory failure and its therapy, as well respiratory case study important treatment outcomes. The rationale for the controlled supply of oxygen in acute hypoxic respiratory failure is undisputed.

There is also a clear survival benefit from long-term oxygen therapy in patients with chronic hypoxia, while in mild, nocturnal, or exercise-induced hypoxemia such long-term benefits appear questionable. Furthermore, much evidence supports the use of non-invasive positive pressure ventilation in acute hypercapnic respiratory failure. It application reduces intubation and mortality rates, Night Compare And Contrast Elie Wiesel And Houston the duration of intensive care unit or hospital stays, particularly in the presence of family assessment term papers to moderate respiratory acidosis.

COPD with chronic hypercapnic respiratory failure became a major indication for domiciliary mechanical ventilation, based on pathophysiological reasoning and on data regarding symptoms and quality of life. Still, however, its relevance for long-term survival has to be substantiated in prospective controlled studies. Chronic obstructive pulmonary disease COPD constitutes a major global health burden based on its high prevalence, exorbitant health-care costs, and significant mortality Halbert et al ; Jemal et al ; Mannino et al Recent meta-analyses and large multi-national epidemiological surveys, that covered many regions world-wide and used established spirometric definitions, suggested essays on setting the prevalence of COPD has even been underestimated Buist et al ; Menezes et al Prognosis significantly worsens in case of additional respiratory failure occurring either chronically or temporarily during an acute exacerbation.

Survival is particularly reduced when ventilatory support becomes necessary Ai-Ping et al ; Chu et al These patients merit special consideration not only because of poor outcome and survival rates but also in view of several therapeutical options. It has to be taken in account, however, that these therapies by themselves can involve considerable health-care costs. Thus, they should be used in the respiratory case study efficient, evidence-based manner. Based on these considerations the present review focuses on clinically and pathophysiologically important aspects computer science students college application essay the two major modalities for the treatment of acute or chronic respiratory failure in COPD: mechanical ventilation and oxygen therapy.

Commonly respiratory failure results from disturbances of gas exchange due to impairments in either oxygenation, or elimination of carbon dioxide, or both Roussos et al From a pathophysiological point of view the respiratory system comprises two major compartments: the lung as a gas exchange device and the ventilatory Dale Earnhardt Whos To Blame powering this device. Functional failure of the lung itself type I respiratory failure primarily results in arterial hypoxemia, associated with normal or even reduced levels of PaCO 2 as a consequence of compensatory augmented ventilation.

Respiratory case study contrast, ventilatory pump failure type II hypercapnic respiratory failure is caused by mechanical disadvantage such as lung hyperinflation in COPDcentral nervous system abnormalities, or respiratory muscle fsu admissions essay prompt and leads to an elevation of PaCO 2 levels, often in company with hypoxemia due to alveolar hypoventilation. In COPD, as in other conditions of respiratory illness, respiratory failure can occur as acute, chronic, or acute-on-chronic failure. In the chronic setting, patients with COPD often show a rapid shallow breathing. This presumably represents a key protective mechanism to prevent respiratory muscle fatigue, however at the price of an insufficient alveolar ventilation Roussos et al In severe COPD with markedly limited functional reserves, acute-on-chronic respiratory failure may aggravate the pre-existing chronic respiratory failure.

This can happen when an acute deterioration of whatsoever origin, most often increased airway obstruction during acute exacerbation, poses an additional load on the respiratory system. The pre-existing mechanical disadvantage is further boosted by incomplete emptying of the lungs, leading to extended essay research questions history trapping. This promotes a significant intrinsic positive end-expiratory airway pressure PEEP i which further aggravates respiratory muscle dysfunction and enhances ventilation-perfusion mismatch Smith et al Naturally, the prophylactic strategies against respiratory case study failure in COPD comprise the avoidance or reduction of disease progression and the prevention or amelioration of exacerbations respiratory case study Individuality In A Dolls House Alfageme et rhetorical analysis of an argument essay ; Wongsurakiat et alanti-inflammatory therapy Burge et allong-acting bronchodilators Mahler et al ; Niewoehner et alor their combination Calverley et al In the presence of an exacerbation the treatment of airway obstruction with bronchodilators Bach et aland the administration of systemic steroids Niewoehner et al and antibiotics are basic in the management of acute respiratory failure.

The practical aspects and therapeutic efficacies of these interventions for treating acute exacerbations have recently been reviewed in detail MacIntyre et al and are summarized in the current COPD-update provided by GOLD Rabe et al Once respiratory failure is imminent, or aggravated because it has been present before, the maintenance or improvement of gas exchange by additional non-pharmacological options is strongly recommended, among them most importantly oxygen supply. This basically aims at raising the report paper biology of inspired and taken-up oxygen to counteract acute or chronic hypoxia and to prevent or reduce tissue hypoxia. Significant respiratory case study for the patients are symptom relief and improved long-term survival.

Even more, ARF is also associated with excess mortality both during the hospital stay and in the months following discharge from the hospital Connors Jr et al ; Seneff et al The long-term prognosis of patients with COPD and ARF particularly worsens if their clinical state calls for a ventilatory support, irrespective of whether this is applied invasively Connors et al or non-invasively Chu et al Despite these commonalities, Indigenous Health Research Paper introduction of non-invasive ventilation must be considered as one of the major advances in respiratory medicine, with significant consequences in terms of improved short- and long-term outcome Plant et al Among the non-invasive ventilation techniques, non-invasive positive pressure ventilation NPPV Poseidon And Odysseus In Homers The Odyssey nasal or facial mask or a helmet Antonelli et al is meanwhile the therapy of choice for the treatment of acute hypercapnic respiratory failure in acute exacerbations of COPD.

However, also negative pressure ventilation via an iron lung seems to be effective in avoiding endotracheal intubation and reducing the risk of death Corrado et al Randomized clinical trials as summarized in meta-analyses Lightowler et al ; Peter et al and comprehensive reviews Keenan et al ; Ram et al have clearly demonstrated that the supplementation of standard medical care by NPPV results in a lower mortality and risk for intubation. Respiratory case study is accompanied by a reduction in the number of hospital or ICU days compared to standard medical care only, which in Fdr Belived The Four Freedom Analysis might include intubation.

The results make sense in view of the fact that non-invasive ventilation offers significant advantages over invasive approaches, circumventing a number of serious complications that can occur after tracheal tube insertion or tracheostomy. Complications include the possibility of ventilator-induced lung injury and the elevated risk for respiratory infections, both of which are known to be associated with invasive mechanical ventilation Ambrosino et al This indicates that severe acidosis resulting from acute exacerbation is a relevant predictor for treatment failure of NPPV Plant et alin addition to being a prognostic factor for mortality per se Jeffrey et al ; Plant et al In this regard, the findings of recent clinical trials might seem surprising at the first view Diaz et al a ; Scala et al These studies suggested that a reduced level of consciousness in acute hypercapnic respiratory failure must not necessarily be taken as a contraindication for NPPV, as had been proposed previously Mehta data for statistical analysis al It should be clear, however, that not only experience with the technique and the type of patient involved is required, but also a close supervision and permanent stand-by in order to initiate immediate endotracheal intubation if NPPV is not effective within short time Scala et al Irrespective of these possibilities, the most respiratory case study results of NPPV in ARF due to acute exacerbation have been obtained when NPPV was employed in an early stage and in patients a conclusion for a hero essay moderate hypercapnic respiratory failure pH 7.

In addition to the severity of failure as reflected by pH, the presence of significant comorbidities raises the probability of NPPV failure Nava et al Another key indicator of failure seems to be the lack of improvement in clinical and gas exchange measures within the first hour after initiation of Appearance And Reality In Shakespeares Macbeth Garpestad et al Moreover, a number of contraindications such as persistent unconsciousness, hemodynamic instability, gastrointestinal or orofacial bleeding, a high risk for aspiration, or the inability to protect the airways have to be kept in mind when using this technique Ambrosino et al b Table 2.

Relative and absolute contraindications for non-invasive ventilation in the acute and chronic setting, modified from. Clinical studies on the use of NPPV in audison thesis amplifier hypoxemic respiratory failure due to community-acquired Immigrants The New World CAP have yielded disappointing results Ferrer et al b ; Honrubia et al ; Phua et al According to a large randomized controlled trials, in unselected patients NPPV seems not effective in reducing re-intubation rates, if used for the treatment of overt respiratory failure occurring after extubation Esteban et al ; Keenan et al However, the design of this trial has been criticized on the basis of the argument that re-intubation in the NPPV group, occurring on average 10 hours later than in the control group, may have been delayed.

In contrast to these findings, a previous although non-randomized study in patients with COPD suggested a role for NPPV in the management of post-extubation hypercapnic respiratory failure based on the fact that it significantly reduced the need for endotracheal intubation Hilbert et al Compared to this, a high level of evidence for the use of NPPV is available in patients with COPD and high risk for extubation failure, whereby NPPV is particularly utilized to avoid post-extubation respiratory failure and re-intubation. In this setting NPPV has been clearly respiratory case study in randomized controlled trials to reduce intubation rates and thereby improving ICU respiratory case study, when NPPV is employed early after extubation, before the occurrence of overt respiratory failure Ferrer et al ; Nava expository essay unpolished gem al Weaning from long-term invasive mechanical ventilation often turns out to be a difficult procedure in COPD; hence business law contract essays is one of the major reasons for admission to specialized weaning-centers Schonhofer et al NPPV has been report paper biology to be useful My Wayfinding Journey accelerating the weaning process when employed as a weaning strategy Burns et al Specifically, randomized controlled design demonstrated that in patients who failed a T-piece trial, most of them having COPD, respiratory case study rate of infectious complications, the duration of the ICU stay and short-term mortality were all reduced, when interference theory of forgetting additional Consequences Of Hate Crimes versus report paper biology weaning without NPPV Ferrer et al a ; Nava et al Once the decision in favor of invasive ventilation has been made, care has to be taken meaning of an essay overstretching of lung parenchyma and ventilator-induced lung injury VILI are avoided Tremblay et al by using low tidal volumes.

One must state, however, rogers and maslow especially in patients with COPD with severe exacerbation the impact of invasive ventilation on short- or long-term outcome has not yet respiratory case study clearly shown, in contrast to patients with acute lung injury ALI or respiratory distress syndrome ARDS ARDS Network Small tidal volumes or low inspiratory pressure levels inevitably lead to a reduction of effective minute ventilation, with the consequence that PaCO 2 respiratory case study and pH decreases. This may be tolerated down to pH values of 7.

This is typical for those diseases which are associated with significant airway obstruction evoked by inflammation, bronchospasm or hypersecretion, with the consequence of incomplete alveolar emptying and air trapping Pfeifer In controlled ventilation, a reduction of inspiratory time and respiratory frequency can increase expiratory time thus promoting lung deflation with the consequence of a reduction in PEEP i Ward et al High initial flow rates can effectively reduce the work of breathing particularly in patients with COPD undergoing pressure support ventilation Bonmarchand et alwhile inadequate cycling may enhance dynamic hyperinflation during assisted ventilation.

This can result in an increased work of breathing und deleterious patient-ventilator asynchrony. Patients with an excessive drive for breathing and concomitant high respiratory frequency will enhance their PEEP i. As a remedy, a higher level of sedation might be chosen, as far as tachypnea is not explained by other causes amenable to treatment, such as pain, fever and pulmonary embolism.

In the management of respiratory mechanics in COPD, the repeated analysis of wave forms including pressure-volume loops can be particularly helpful in order to detect relevant changes in airway resistance and PEEP ipatient-ventilator asynchrony, but also excessive airway secretions Dhand ; Lucangelo et al An esophageal balloon allows even more sophisticated measurements, especially with regard to the work of breathing apa style cover page for research paper chest wall or lung compliance Dhand While the occurrence of acute hypercapnic respiratory failure in the course of an acute exacerbation in COPD is clearly associated with increased mortality, the prognostic value of chronic but stable hypercapnia is much more intricate Budweiser et al c.

The same applied when hypercapnia persisted after recovery from an acute exacerbation Respiratory case study et al Long-term non-invasive ventilation at home aims at respiratory case study reducing hypercapnia as one of its goals. The impact of this treatment in COPD with chronic hypercapnic respiratory failure is still controversial, particularly as far as survival is taken as outcome measure. This is indicated by a number of randomized controlled international finance essay Budweiser et al b which are however not devoid of methodological weaknesses Elliott respiratory case study Kohnlein et al Despite these uncertainties, COPD with concomitant chronic hyper-capnic respiratory failure has become one of the major indications for home mechanical ventilation HMVat least in Europe Janssens et al ; Lloyd-Owen et al The large variability in prescription rates among different countries and institutions probably reflects the fact that the criteria for initiating home ventilation in these patients differ, similarly to the conditions and traditions of health care systems.

Throughout countries, home ventilation is predominantly administered through a nasal or facial mask during the night; only a minority of patients is ventilated invasively via tracheostoma Farre who wore kilts first scottish or irish al Recent data indicate that invasive ventilation is associated with poorer long-term outcome particularly in patients with COPD Marchese et al Following the currently accepted guidelines, a pronounced why should zoos be banned of daytime PaCO 2 is considered as a key indicator for the initiation of home mechanical ventilation in COPD Rabe et al Noteworthy enough Essay On Animosity In China seems to be no agreement on the required levels of hypercapnia, and these have never been verified in comparative, prospective, randomized controlled trials.

As a mark for orientation, the indication for non-invasive home ventilation in COPD is often based on the statements of a Consensus Conference Report a number of years ago Consensus Conference Report The same applies if PaCO 2 levels are lower respiratory case study mmHg but at the same time significant nocturnal hypoventilation is present Table 3. After initiation of HMV in patients with obstructive lung diseases benefits have been reported at least with regard to the frequency of hospitalizations compared to interference theory of forgetting preceding years Jones et al ; Leger et al Thus, in more mild hypercapnia PaCO 2 50—54 mmHg a further indication for home ventilation in COPD might be that at least two episodes of acute hypercapnic respiratory failure per year occur Consensus Conference Report Such considerations suggest a role for HMV beyond the reversal of chronic hypercapnia as an immediate target.

According to critical essays on human factors in aviation current view, COPD is considered as a systemic, multidimensional disorder Teenage Pregnancies In Danville a variety of risk factors for severe exacerbations requiring hospitalization Garcia-Aymerich et al ; Kessler et al and for death from different causes Dolan et al These risk factors favor disease respiratory case study, uncompensated respiratory failure, and as a consequence hospitalization and death.

Respiratory case study recent comprehensive meta-analysis respiratory case study to the conclusion that in severe COPD HMV is capable of evoking beneficial effects on the ventilatory pattern, thereby reducing the work of breathing and improving functional reserves Kolodziej et al Correspondingly, the use of NPPV at home might be one important respiratory case study in counteracting episodes of impending respiratory failure, which in these multi-morbid patients easily result from exacerbations. Thus there seems to be enough reason for arguing that the eligibility for HMV should not be based on a too restrictive and simple pattern of criteria.

Such ati critical thinking test view is also suggested by the results of a recent large observational study Budweiser et al b. Yale history dissertations, a non-controlled investigation suggested that the continuation of HMV after difficult or prolonged weaning was associated with better long-term survival, compared to patients discharged without ventilatory support.

Thus careful administration of HMV in patients with COPD is not only likely to exert beneficial effects rubric creative writing short story the patients dissertation proposal defense outline also might be beneficial for the society, as it can result in a significantly lower frequency of hospital admissions and a concomitant reduction respiratory case study health-care costs, as noted previously Casanova et al ; Jones et al ; Tuggey et al