Patient Background

You have been tasked Priority 2 to a 75 year old man with chest tightness and shortness of breath.  On your arrival you find a very thin, elderly man sitting on a chair with his arms braced on his knees.  He looks very dyspnoeic.  His initial observations are:

Respiratory rate	45 breaths/minute
Heart rate	120 beats/minute
Blood Pressure	95/50 mmHg
Oxygen saturation	82%
Glasgow Coma Score	13 (E=3,V=4, M=6)

The man’s name is Mr Wenham, and he is only able to speak single words.  His wife tells you that his breathing is never very good, because he smoked far too much.  She says he sometimes struggles to walk around the house.

Symptoms	Shortness of breath, chest tightness, cough
Onset	“His breathing has been particularly bad for the last two days and much worse for the last hour or so”
Chest examination	Barrel chested, little chest wall movement
Breathing sounds	Very quiet breath sounds, occasional wheeze
Jugular veins	Elevated 5cm

You form the view that Mr Wenham is suffering from an exacerbation of Chronic Obstructive Pulmonary Disease (COPD).  You administer supplemental oxygen, atrovent and salbutamol (following local guidelines), and prepare for the 60 minute journey to hospital.

1. Describe the underlying pathology of COPD and the common pathological characteristics of the condition. Discuss the impact these pathological changes have on normal function, including how alveolar ventilation might be different in Mr Wenham compared to a normal individual.(20 marks)

1. Discuss why you would administer salbutamol and describe how it works at the cellular level.(10 marks)

Mr Wenham’s oxygen saturation improves with supplemental oxygen but he remains tachypnoeic, tachycardic and hypotensive.  On arrival at the Emergency Department you go straight to the resuscitation room and an arterial blood gas sample is taken and analysed immediately with the following results:

pH	7.12
PaO2	100 mmHg.
PaCO2	110 mmHg
HCO3	38

1. Discusswhy they would take an arterial blood gas and explain what the results mean and how they relate to the pathophysiology you described.(10 marks)

The emergency department staffsuggest you may have given Mr Wenham too much oxygen. They say they are going to remove the oxygen.

1. Overview the normal physiological control of breathing. Then, identify and discuss the issues surrounding the use of supplemental oxygen therapy in patients with severe exacerbations of COPD. What problems can it cause and why? (20 marks)

1. When considering his blood gas analysis, do you think it is a good idea to remove Mr Wenham’s oxygen and have him just breathing air? Provide an argument supporting why it is OR why it is not.(10 marks)

The emergency department consultant returns from his lunch break to interrupt the oxygen debate.  He suggests that Mr Wenham needs BiPAP.

1.  What is BiPAP?  How might BiPAP help to improve Mr Wenham’s clinical condition? (10 marks)

Three days later, after 18 hours of BiPAP, corticosteroids and physiotherapy, Mr Wenham is much improved.  The respiratory physician responsible for his care orders spirometry.  This shows:

FEV1	0.75 litres
FVC	1.5 litres
FEV1/FVC	50%

1. What is spirometry?  (5 marks)

1. Discuss the significance of the results by examining the differences between Mr Wenham’s spirometry and that of a normal individual? (10 marks)

1.  How does the pathology of COPD explain these differences? (5 marks)

 Integrated Clinical Case

Answer Template (cut and paste into a new document).

1. Describe the underlying pathology of COPD and the common pathological characteristics of the condition. Discuss the impact these pathological changes have on normal function, including how alveolar ventilation might be different in Mr Wenham compared to a normal individual. (20 marks)

1. Discuss why you would administer salbutamol and describe how it works at the cellular level. (10 marks)

1. Discuss why they would take an arterial blood gas and explain what the results mean and how they relate to the pathophysiology you described. (10 marks)

1. Overview the normal physiological control of breathing. Then, identify and discuss the issues surrounding the use of supplemental oxygen therapy in patients with severe exacerbations of COPD. What problems can it cause and why? (20 marks)

1. When considering his blood gas analysis, do you think it is a good idea to remove Mr Wenham’s oxygen and have him just breathing air? Provide an argument supporting why it is OR why it is not.(10 marks)

1. What is BiPAP?  How might BiPAP help to improve Mr Wenham’s clinical condition? (10 marks)

1. What is spirometry?  (5 marks)

1. Discuss the significance of the results by examining the differences between Mr Wenham’s spirometry and that of a normal individual. (10 marks)

1.  How does the pathology of COPD explain these differences? (5 marks)

ANSWER EACH QUESTION IN ONE PARAGRAPH

1. Job Research

What sorts of research strategies would be helpful to use in preparing for a job application and interview? Explain your response in detail.

1. Osteoarthritis Treatment

According to the National Institutes of Health, osteoarthritis (OA) is the most common form of arthritis and affects approximately 27 million Americans. Research and report on what OA is, why it is so prevalent in our society, who’s at risk and what the long-term complications are. There are a number of treatment options for OA, from over the counter (OTC) to prescription medications, physical therapy, surgery, joint replacement and alternative therapies (such as chiropractic care and acupuncture) – each with their own benefits and side effects.

What is the best treatment option for OA for a 50-year-old individual who has moderate osteoarthritis in a knee joint with no torn cartilage or ligament damage? Please be specific with your treatment recommendations and justify your reasoning and advice with your research and pros/cons of your therapies. Is there one that is better over the other?