Patient Initials: Ivory, L.
Subjective Data: a 65 years-old Caucasian woman who suffered a motor vehicle accident and was discharged from the hospital approximately two months ago. She currently complains of severe wheezing, shortened breath and a cough she has on a daily basis at least once time. It is hard for her to talk because she constantly pauses in order to catch her breath.
Chief Complaint: shortened breath, severe wheezing and cough, as well as severe asthma attacks, the number of which significantly grew after the accident.
History of Present Illness: after the accident and clinical treatment, the patient experienced frequent asthma attacks – more than four times per week. She also had a serious MVA ten weeks ago and a post-traumatic seizure two weeks after the accident. The seizure activity was liquidated after the patient started anticonvulsant phenytoin.
PMH/Medical/Surgical History: the patient has had periodic asthma attacks since her early 20s. Three years ago, she was diagnosed with mild congestive heart failure and placed on a sodium-restrictive diet and hydrochlorothiazide. Last year enalapril was prescribed to the patient because of worsening CHF, and symptoms were well controlled.
Significant Family History: The patient’s father died at the age of 59 of kidney failure to HTN, and her mother died at the age of 62 of CHF.
Social History: The patient denies smoking and taking alcohol but drinks a lot of caffeine. As a rule, she drinks four cups of coffee and four diet colas on a daily basis.
Review of Symptoms:General: positive for exercise intolerance, denies swelling in the extremities; Head: denies headaches; Respiratory: positive for shortness of breath, coughing, wheezing; Musculoskeletal: denies seizures.
Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
Vital Signs after Albuterol breathing treatment: BP 134/79, HR 80, RR 18
Physical Assessment Findings
General: Pale, well-developed female appearing anxious.
HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted.
Carotids: Regular rate and rhythm normal S1 and S2.
Lungs: Bilateral expiratory wheezes.
Abdomen: soft, non-tender, non-distended, no masses.
Rectum: Guaiac negative.
Extremities/Pulses: +1 ankle edema on the right, no bruising, normal pulses.
Neurologic: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Test Results: Na – 134, K – 4.9, Cl – 100, BUN – 21, Cr – 1.2, Glu – 110, ALT – 24, AST – 27, Total Chol – 190, CBC – WNL, Theophylline – 6.2, Phenytoin – 17. Chest Xray – Blunting of the right and left costophrenic angles
- Peak Flow – 75/min; after albuterol – 102/min
- FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Assessment: The tests and physical examination show that the patient is likely to have one of the three diagnoses. They are acute bronchospasm (J96.22), moderate persistent asthma with (acute) exacerbation (J45.41), or other specified pulmonary heart diseases (I27.89) (Billing and coding: Respiratory care, n.d.). The first two diagnoses presume preliminary plans of care and reducing the symptoms the patient has, while the third one requires broader testing to establish the final diagnosis. At this point, the patient is more likely to have moderate persistent asthma with exacerbation, as it may be caused by the stress she experienced for the past two months. Severe stress similar to the patient’s suffering during the accident may become the reason for asthma exacerbation and other lung inflammations (Miyasaka et al., 2018). Moreover, the exacerbation may be caused by allergic reactions to the medicine prescribed to the patient (Miyasaka et al., 2018). In any case, additional tests and lung MRI are required to exclude severe lung and heart conditions and pathologies.
Plan of Care: After the patient’s diagnosis is established and clearly described, it will be possible to prescribe suitable treatment and prevention measures. If the patient has asthma exacerbation, the treatment will consist of inhaling bronchodilators and systematic use of corticosteroids (Treatment of acute asthma exacerbations, 2022). Since the patient tried albuterol inhalations, and they seemed to help her, the physician may either leave her with this medication or prescribe another salbutamol-consisted one. In addition, the doctor may treat her with systematic corticosteroids such as prednisone, prednisolone, and methylprednisolone. She may be recommended to supplement oxygen if her state is unstable or worsens. If any improvement in the patient’s state will not be observed, she may face hospitalizations and consultations with a pulmonologist or cardiologist since the symptoms may indicate heart disease.
If the patient has bronchospasm, the physician should prescribe bronchodilators that will help reduce the symptoms. The most commonly prescribed bronchodilators usually are beta-agonists, theophylline, and anticholinergics (Huizen, 2017). They may be in the forms of tablets, inhalators, or in liquid forms. The treatment of bronchospasm is individual for each patient and depends on the severity of symptoms they have. However, the most often used medications for treating the disease include short-acting bronchodilators or a combination of long-acting bronchodilators and steroids.
The third diagnosis, which concerns other specified pulmonary heart diseases, requires additional and broad medical testing before prescribing any treatment. The symptoms the patient has may relate to heart disease, and in that case, the consultation of a cardiologist is required. If the disease is related to the lungs, the treatment will depend on the lung MRI and X-ray results. It may include the prescription of bronchodilators to reduce spasms and specific medication to liquidate the reason for their development.
Billing and coding: Respiratory care (respiratory therapy). (n.d.). MCD. Web.
Huizen, J. (2017). What is bronchospasm and what causes it? Medical News Today. Web.
Miyasaka, T., Dobashi-Okuyama, K., Takahashi, T., Takayanagi, M. & Ohno, I. (2018). The interplay between neuroendocrine activity and psychological stress-induced exacerbation of allergic asthma. Allergology International: Official Journal of the Japanese Society of Allergology, 67(1), 32-42.
Treatment of acute asthma exacerbations (2022). MSD Manual. Professional version. Web.