Sample Assessments
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Mr. Henry Navarro, a 62-year-old Hispanic male, is seeking care. In a previous case study, his hypertension, type 2 diabetes, hyperlipidemia, and coronary artery disease (CAD) were addressed. His prescribed medications include Losartan potassium/hydrochlorothiazide for blood pressure, Atorvastatin for hyperlipidemia, Metformin for diabetes, and Clopidogrel and Aspirin as blood thinners to reduce the risk of stent thrombosis. This study focuses on his chronic obstructive pulmonary disease (COPD) and depression. Using clinical guidelines, the treatment plan, medication side effects, interactions, and patient education strategies will be examined to improve adherence and health outcomes.
Mr. Navarro was recently diagnosed with COPD and was prescribed an albuterol inhaler. However, he continues to experience shortness of breath and a productive cough. COPD is a chronic lung disease characterized by dyspnea, cough, and airflow obstruction due to airway and alveolar abnormalities (King Han et al., 2023). COPD is classified into Groups A, B, and E, based on symptoms and exacerbation history. Given that Mr. Navarro has had hospitalizations due to exacerbations, he falls into Group E, which includes patients at high risk for exacerbations (≥2 per year or ≥1 hospitalization) (Ferguson & Make, 2023).
A major risk factor for COPD is cigarette smoking, and both duration and quantity of smoking influence disease severity (King Han et al., 2023). Mr. Navarro reports a 46-year smoking history and currently smokes one pack per day. Given his continued exacerbations, his treatment plan should be adjusted to improve symptoms and quality of life.
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), patients with severe COPD should receive dual long-acting bronchodilator therapy, combining a long-acting β2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) (Miravitlles et al., 2022). Additionally, inhaled corticosteroids (ICS) are recommended for patients with blood eosinophils ≥300 cells/µL. To enhance adherence and reduce costs, a fixed-dose LABA-LAMA inhaler is preferred over separate inhalers. Umeclidinium 62.5 mcg/vilanterol 25 mcg (Anoro Ellipta), taken once daily, is an effective choice with minimal adverse effects, including pharyngitis, diarrhea, and extremity pain in ≤2% of patients (Medscape, n.d.).
There is a potential drug interaction between hydrochlorothiazide (part of his blood pressure medication) and umeclidinium/vilanterol, as both can cause serum potassium reduction. However, routine potassium monitoring can help manage this risk (Medscape, n.d.).
Since smoking is the primary cause of COPD progression, Mr. Navarro must receive personalized smoking cessation support. Tobacco cessation is often difficult, requiring individualized approaches based on readiness, method preference (gradual vs. abrupt), and willingness to use pharmacologic aids (Rigotti, 2021).
Nicotine replacement therapy (NRT) helps relieve withdrawal symptoms without tobacco exposure. It is safe for patients with cardiovascular disease and is most effective when combining long- and short-acting formulations (Rigotti, 2023). Mr. Navarro should start with a nicotine transdermal patch (21 mg/day) for six weeks, then taper to 14 mg/day for another six weeks, followed by 7 mg/day for two weeks before discontinuation. A short-acting NRT, such as lozenges or gum, should be used for breakthrough cravings (Rigotti, 2023).
Additionally, behavioral counseling is recommended. Providing state quitline support can enhance long-term abstinence success (Rigotti, 2021).
Mr. Navarro should receive education on inhaler technique, airway clearance, increasing physical activity, and breathing exercises. Poor inhaler technique is common, particularly in older adults with manual dexterity issues (GOLD, 2023). A teach-back method should be used to confirm proper inhaler use. If Mr. Navarro has difficulty generating sufficient inhalation force, an alternative formulation may be necessary.
Increased physical activity improves respiratory endurance, while controlled breathing techniques help conserve energy and reduce dyspnea. Annual influenza, pneumococcal, shingles, and COVID-19 vaccinations are also recommended for infection prevention (GOLD, 2023).
Mr. Navarro reports feeling depressed due to his declining functional ability and lack of interest in daily activities. Although he denies suicidal ideation, he requests pharmacological intervention for depression.
A suitable option is Bupropion XL (Wellbutrin XL) 150 mg/day for three days, increasing to 300 mg/day if tolerated. Bupropion is particularly beneficial as it aids in both depression treatment and smoking cessation. However, Wellbutrin SR carries a higher risk of hypertension, making Wellbutrin XL a preferable alternative. Close blood pressure monitoring is still necessary due to his hypertension history (Medscape, 2023).
Common side effects include headache, dry mouth, weight loss, agitation, and dizziness (Medscape, 2023). Mr. Navarro should be informed that antidepressants require several weeks to take effect and that therapy should be continued even if initial improvement is slow. Additionally, he should be referred to a therapist or psychiatrist for further evaluation and support.
This case study highlights the importance of individualized treatment in managing COPD and depression. Mr. Navarro’s care plan should focus on optimizing pharmacologic therapy, ensuring adherence, implementing smoking cessation strategies, and addressing mental health needs. With a comprehensive, patient-centered approach, his symptoms can be controlled, and his quality of life significantly improved.
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