Peer Responses:
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- Geriatric Chronic Condition In this case study, the 68-year-old male patient is presenting with complaints of a persistent dry cough and urinary frequency occurring for months. He endorses a past medical history of hypertension and a 20-pack year history of smoking cigarettes despite past attempts to quit. His family history is unknown. There are several differentials to consider in respect to the patient’s chief complaints.Differential Diagnoses1. Chronic Obstructive Pulmonary Disease (COPD)It is reasonable to consider the patient’s symptom of cough is related to COPD in lieu of the patient’s 20 pack year history of smoking. The most common symptom of COPD is cough and one of the most significant risk factors is tobacco habituation (Vogelmeier et al., 2020).1. Benign Prostatic Hypertrophy (BPH)Common in aging men, BPH is a condition where the prostate enlarges and can result in lower urinary tract symptoms (LUTS) presenting with urinary frequency, urinary retention, and recurrent urinary tract infections (Foo, 2019). Based on this patients age of 68 years and urinary frequency, and overactive bladder, it is reasonable to include BPH in the differentials.1. Sjögren’s SyndromeSjögren’s syndrome is an autoimmune disorder that often presents with patient’s complaining of xerostomia and xerophthalmia resulting from dysfunction of the lacrimal and salivary glands (Negrini et al., 2022). It is important to note that Sjögren’s syndrome can also affect varying other body systems and is not confined to the eyes and oral cavity. Some patients will present with complaints of a persistent dry cough and urinary symptoms lending to the clinical scenario of systemic involvement referred to as the Sicca complex (Negrini et al., 2022). In this scenario, the patient is presenting with complaints that align with Sjögren’s Syndrome.Based on the patient’s history of present illness, past medical history, and chief complaints, it is likely the patient is experiencing symptoms relating to chronic smoking and the aging process leading the index of suspicion toward the diagnoses of COPD and BPH.Smoking Cessation Support Patients desiring to participate in a smoking cessation program have options to consider in respect to the available resources in the community. Kick it California is a free program to that serves to assist the community to successfully cease tobacco habituation. The programs are individualized and provide strategies and a personal coach to support the person with efforts to quit smoking (CDOPH, 2023). California has a Smoker’s helpline with available counseling sessions and a plan for success that is free for the public, this is an important part of Santa Barbara Cottage Hospital’s Breath Well program (Cottage Health, 2023). Patients of the Santa Barbara Neighborhood Clinics are also eligible for mental health counseling for smoking cessation regardless of ability to pay.Diagnostic PlanDiagnostics for this patient includes shared decision making with recommendations for routine lab to include a complete blood count, complete metabolic panel, and prostate specific antigen testing to assess for hemodynamic stability. It is important to conduct a urinalysis to assess for infection, bleeding, protein, specific gravity, and glycosuria (Miernik & Gratzke, 2020). Measuring the PSA is clinically relevant to the possibility of elevations relating to BPH, prostate cancer, and prostatitis (Foo, 2019). A less invasive examination of the prostate can be accomplished with an ultrasound to assess the intravesical prostatic protrusion (IPP) and can readily identify a prostate adenoma (Foo, 2019). A measure of urinary flow can be obtained by a noninvasive uroflowmetry that can also detect volume (Miernik & Gratzke, 2020). The IPSS score or the International Prostate Symptom Score can identify the severity of the lower urinary tract symptoms (LUTS) (Miernik & Gratzke, 2020). Diagnostics for COPD are accomplished beginning with a questionnaire assessment in primary care to identify undiagnosed respiratory disease or the CAPTURE risk assessment, chest radiographs, CT-scans, blood gases, anti-trypsin deficiency (AAT) testing, spirometry, and a 6-minute walk test (Foo, 2019). Diagnosing Sjögren’s Syndrome can rule out other pathology and is accomplished by lab testing for anti-nuclear antibodies (ANA), rheumatoid factor (RF), auto-antibody testing, ultrasound and biopsies of the salivary glands, and lacrimal function testing and ocular staining (Negrini et al., 2022). Treatment/EducationThe treatment plan for this patient begins with providing resources for smoking cessation as he has tried in the past leading the notion he may be open to attempting to quit again. Based on shared decision making, he will be referred to counseling to help provide the support he needs to successfully quit smoking. Next, the patient will be referred for nutritional counseling, pulmonary rehabilitation, and exercise prescription to aid with conditioning to help foster a healthy lifestyle. Education focuses on successful methods to quit smoking, avoidance of known triggers of COPD and cough, and infection control practices to reduce risks for respiratory infections (Vogelmeier, 2020). Based on outcomes of his diagnostics for COPD, he will be prescribed commonly used therapies such as the long-acting beta agonist Salmeterol Diskus, 50 mcg, one inhalation 2 times daily and at least 12 hours apart (Vogelmeier et al., 2020). Education will be provided in a written handout depicting the correct use of the diskus. Treating the symptoms of confirmed BPH involves shared decision making in respect to life quality and will include medication to reduce prostate enlargement thereby facilitating complete urination without obstruction. The medication Flomax is an alpha1-receptor inhibitors and functions to inhibit the smooth muscle cells of the prostate cell and bladder outlet from constricting under the influences of norepinephrine (Miernik & Gratzke, 2020). Dosing is generally 0.4mg orally daily and patient education includes to monitor for side effects of dizziness, lightheadedness, and ejaculatory dysfunction (Miernik & Gratzke, 2020). Education also includes the avoidance of caffeine and alcohol, adjust timing of intake of fluids daily, exercise, and healthy diet (Miernik & Grtzke, 2020). Because the patient is taking a concomitant antihypertensive, it is important to educate the patient regarding fall risks relating to possible orthostatic hypotension, and to rise to stand slowly. Education should include the patient notifying the provider if resistant dizziness or lightheadedness occurs and to remain hydrated on a daily basis. Referrals In this case if the patient does not report therapeutic responses to the treatment plan than it is reasonable to refer to urology for the urinary symptoms, and pulmonology for the cough. Of importance is educating the patient to maintain a health and wellness diary to document responses, concerns, and symptoms for future provider appointments.Follow-up Recommended follow up should occur in 2 weeks or sooner to review diagnostics and response to the prescribed treatment plans. ReferencesCalifornia Department of Public Health (2023). Kick it California. Retrieved from: https://kickitca.org/Cottage Health (2023). Breathe Well Program. Retrieved from: https://www.cottagehealth.org/app/files/public/610…Foo K. T. (2019). What is a disease? What is the disease clinical benign prostatic hyperplasia (BPH)?. World journal of urology, 37(7), 1293–1296. https://doi.org/10.1007/s00345-019-02691-0Miernik, A., & Gratzke, C. (2020). Current Treatment for Benign Prostatic Hyperplasia. Deutsches Arzteblatt international, 117(49), 843–854. https://doi.org/10.3238/arztebl.2020.0843 Current Treatment for Benign Prostatic Hyperplasia. Deutsches Arzteblatt international, 117(49), 843–854. https://doi.org/10.3238/arztebl.2020.0843Negrini, S., Emmi, G., Greco, M., Borro, M., Sardanelli, F., Murdaca, G., Indiveri, F., & Puppo, F. (2022). Sjögren’s syndrome: a systemic autoimmune disease. Clinical and experimental medicine, 22(1), 9–25. https://doi.org/10.1007/s10238-021-00728-6Vogelmeier, C. F., Román-Rodríguez, M., Singh, D., Han, M. K., Rodríguez-Roisin, R., & Ferguson, G. T. (2020). Goals of COPD treatment: Focus on symptoms and exacerbations. Respiratory medicine, 166, 105938. https://doi.org/10.1016/j.rmed.2020.105938less
