Respiratory Examination

Case Scenario

You are a nurse practitioner (NP) at Shady Nook skilled nursing facility and caring for Mr. Sanchez-Jimenez, a 70-year-old Vietnam War veteran. He has advanced COPD from years of smoking. Dr. Smith, your collaborating physician, is ill and so his partner, Dr. Jack joins you on rounds this morning. Dr. Jack has never worked with an NP before.

You and Dr. Jack are called into the room by the RN to evaluate their patient Mr. Sanchez-Jimenez, who is having difficulty breathing today. Following an examination, you decide that he may have an early pneumonia in addition to an exacerbation of his COPD. You propose a plan of care at the bedside including an increase in his nebulizer treatments, addition of oral steroids, and empiric treatment for pneumonia with I.V. antibiotics pending a CBC and CXR report. Dr. Jack hesitates, but then agrees with the plan. You advise the patient who thinks the plan is fine. Dr. Jack then turns to the RN and states “I will write all the orders because ‘glorified nurses’ don’t always have the best documentation, I tell you….” Dr. Jack leaves as he shakes his head.

Matt, the respiratory therapist goes into the room to administer a nebulizer treatment. Shortly afterwards, he catches you and Dr. Jack in the hallway to report that Mr. Sanchez-Jimenez is tachycardic with a HR of 110. Matt suggests a change in nebulizer medication from albuterol to Xopenex. Dr. Jack appears unimpressed and walks away stating, “Everyone thinks they can be a doctor these days! When I want your input, I’ll ask for it.” Matt looks at you in disbelief and states, “I don’t know what to do.” He then adds, “Should we write him up?”