Introduction
Medical practice often encounters cases in that one disease is supplemented by another, which complicates the diagnosis and the choice of the right treatment. In addition, curing measures should cover both the primary diagnosis and its accompanying symptoms to achieve results. The purpose of this paper is to show, by the example of one medical case, the procedure of diagnosis and treatment by using objective and subjective data and determine the research question related to this case.
Subjective reasons
The patient is a 47-year-old African American man who has been admitted to the hospital with multiple complaints. The man said about frequent bone pain in the back and chest, as well as shortness of breath and coughing. The patient claimed that the pain is not constant, but attacks occur quite often. The patient confirms persistent shortness of breath, fatigue, and weight loss; he also notes fever, sweating, and tiredness. The patient also has an infectious disease often. He rejects sore throats, headaches, diarrhoea, problems with urination.
Previously, the patient was diagnosed with blood cancer, precisely multiple myeloma, for the treatment of which he took chemotherapy courses. The disease also was accompanied by anaemia and leukopenia. Chemotherapy resulted in feet neuropathy, as well as a history of pain management. Besides, the patient suffered pneumonia and was admitted to the hospital with DVT and pulmonary embolism. As a result, he was given portocath placement to deliver medication in the fastest and shortest way.
The patient does not use smokeless tobacco, alcohol, or drugs, but he smokes regular cigarettes. The man also noted that he has a sibling who was also diagnosed with multiple myeloma. An additional risk is the patient’ job, since he worked in places where he was exposed to the action of many chemicals, such as gasoline, industrial pesticides, and large doses of radiation.
Objective reasons
The patient’s blood pressure is normal 135/69; pulse increased 105 beats per minute. S1 and S2 heart sounds with regular rate and rhythm. Respirations have difficulty at 12 breaths per minute; 99% oxygen saturation. The patient is awake, pleasant and communicative; speech is clear and fluent. The man is alert and oriented; pupils are equal and reactive to light and accommodation. The mucous membranes are clean and pink without swelling and lesions. Facial signs are bilaterally symmetrical; the skin is clean and has an appropriate colour for ethnicity. The fingertips are pink, and the filling speed of the capillaries is less than 2 seconds on all fingers and toes. There is expiatory wheezing sound on lungs auscultation. Edema + 1 is present in all extremities; dorsalis pedis and posterior tibial pulses +1 bilaterally.
Results of laboratory tests include a WBC 1,8 and hematocrit 22,7%, which are low levels and demonstrate anaemia. Sodium 143 is slightly high and can cause edema of extremities and lungs. Potassium 3.0, carbon dioxide 33, free calcium 7.8 are slightly low; however, after the start of taking medication potassium increased to 3.6, carbon dioxide to 33, free calcium to 7.8. These results also reflect multiple myeloma and anaemia, which cause pain in bones, weight loss, and fatigue.
Current treatment includes Albuterol Inhaler (Ventolin) to normalize function and increase airflow in the lungs, and Budesonide (Formoterol) for symptomatic treatment of exacerbated breathing difficulties. Furosemide (Lasix) to treat fluid build-up and sweating; Prednison (Deltasone) 20 mg to decrease inflammation and increase the number of white blood cells, and Apixaban (Eliquis) 5 mg to prevent blood clots. Amitriptyline (Elavil) 10 mg and Diazepam (Valium) 5mg to reduce bone pain and general pain management. Diphenhydramine (Benadryl ) 50 ml to relieve spasms in the lungs and dilate blood vessels. Elotuzumab (Empliciti IV) for the treatment of multiple myeloma. In addition, the patient needs oxygen therapy through a nasal cannula or tracheotomy of 2 l per minute.
The patient responded adequately to all prescriptions as he was interested in his recovery. In addition, the patient has already experienced medical intervention for curing multiple myeloma last time; therefore, he understands the importance of timely used treatment. Symptoms that prevent him from living normally and doing his routine are also important incentives for receiving medications.
Nursing Diagnoses
The first diagnosis is fatigue and general weakness of the body due to a low level of white blood cells and hematocrit. The second diagnosis is weight loss because of nausea, loss of appetite, and increased thirst, which are consequences of multiple myeloma relapse. The final diagnosis is a chronic obstructive pulmonary disease that demands overcoming such symptoms as coughing, inflammation in the lungs, swelling of the limbs and illnesses described above.
Intervention
The intervention plan includes the normalizing of breathing, elimination of inflammation in the lungs and swelling of the extremities, increasing of appetite, and strengthening of all organs and systems of the body. It is also necessary to control and overcome pain by using medication prescribed by the physician, as well as treat blood diseases, which affect the patient’s condition and course of treatment. These processes include constant monitoring of oxygen saturation and changes in blood structure, regulating and correlating dosage medications for pain management due to the recommendation of the patient’s doctor.
Oxygen therapy and medication for reducing spasms and increasing immunity are mandatory for symptom control and have to be provided to the patient due to his state and prescriptions of the physician. Besides, it is essential to remind the patient about taking medication that prevents the formation of blood clots, as well as the development of renal failure.
Additional nursing intervention is providing education of the patient to continue recovery at home, and prevent symptoms of both COPD and multiple myeloma. A nurse must also provide education to the patient’s family.
The patient also needs to avoid direct and passive smoking as his lungs are already damaged, which causes shortness of breath. A diet with a limited amount of sodium, saturated fats, and simple carbohydrates, but a stable dose of fiber, protein, and vitamins is the need to treat COPD and relieve swelling in the limbs. There is also a need for exercise that helps improve the flow of air in the lungs and strengthen the body in general (Mulhall & Criner, 2016). Thus, medical treatment in the hospital, as well as lifestyle changes at home, will help the patient return to a healthy state.
Evaluation
This case was unusual for medical practice because the diagnosis of COPD was accompanied by multiple myeloma and anaemia, which caused additional symptoms and complicated treatment. The diagnosis was facilitated and at the same time complicated by the patient’s medical history, as the nurses and therapist knew about cancer and chemotherapy, so they consider their consequences. This fact raises the first research question about whether multiple myeloma and anaemia can increase the risk of lung disease and COPD in particular. The research by Tsai et al. (2017) showed that the risk of tuberculosis is higher among patients with multiple myeloma. However, tuberculosis is an infectious disease, but different bacterial infection contribute to the destruction of lung tissue, so the effects of multiple myeloma on COPD are still to be studied.
Moreover, the combination of diagnoses caused additional difficulties in treatment, since it was necessary to control the symptoms of COPD, myeloma, and anaemia. It also complicated the control of pain and the regulation of medications that help relieve symptoms. In this regard, the question arises about the effect of myeloma on the course of COPD and the possibility of its control. Judging by the treatment, myeloma and anaemia make it difficult to treat, since the patient needs to take medication acting on different parts and functions of the organism. At the same time, the therapist must take into account the interaction of all prescriptions and avoid possible side effects.
In addition, one of the most critical factors for recovery and maintaining health is nutrition. However, if the effect of the diet is obvious for diseases associated with metabolic problems, then for COPD, the relationship may not be entirely clear. Nevertheless, a diet is necessary as part of non-medication treatment, since the optimal content of elements and vitamins in the body strengthens all body systems, and also helps to slow the destruction of lung tissue. Besides, according to Sin (2019), people with COPD should reduce the consumption of processed meat, since the high nitrate content in it contributes to oxidative processes and inflammation, which is extremely dangerous for the damaged lungs. Therefore, patients after discharge should be educated not only in the medical treatment of their disease but also in proper nutrition.
Summary
Chronic obstructive pulmonary disease is the result of the patient’s work in harmful conditions and smoking; however, the complexity of the diagnosis and treatment caused multiple myeloma and anaemia, which have similar symptoms. After discharge, the patient must continue medication, as well as change his lifestyle, avoid smoking, eat healthy food, and perform physical exercises. Although such a complex of treatment cannot cure the disease, it will reduce the manifestation of symptoms and allow to return to regular life.
References
Mulhall, P., & Criner, G. (2016). Non-pharmacological treatments for COPD. Respirology, 21(5), 791–809.
Sin, D. D. (2019). Diet and COPD: Are we what we eat? EClinicalMedicine, 14, 5–6.
Tsai, C.-K., Huon, L.-K., Ou, S.-M., Kuan, A.-S., Yeh, C.-M., Lee, Y.-T., … Liu, C.-J. (2017). Risk and impact of tuberculosis in patients with multiple myeloma. Leukemia & Lymphoma, 58(11), 2598–2606.