Patient Initials: N/A (65-year-old Caucasian female)
Chief Complaint: “severe wheezing, shortness of breath and coughing at least once daily”.
History of Present Illness: A motor vehicle accident was the reason for hospitalization several weeks ago. Ten weeks ago, the patient was discharged from the hospital. Post-traumatic seizures occurred 2 weeks after the accident. Anticonvulsant phenytoin started. Asthma attacks (4 times per week) are observed during the past two months.
PMH/Medical/Surgical History: Periodic asthma since the 20s; mild congestive heart failure (3 years ago); sodium restrictive diet and hydrochlorothiazide; enalapril placement to deal with worsened CHF. No surgeries. No allergies. Medications: Theophylline; Albuterol inhaler; Phenytoin; HTCZ; Enalapril.
Significant Family History: Father died because of kidney failure secondary to HTN at the age of 59. Mother died because of CHF at the age of 62.
Social History: denies smoking and alcohol use. She takes 4 cups of coffee and 4 diet colas each day.
Review of Symptoms: Positive for shortness of breath, coughing, wheezing, and exercise intolerance. Denies headaches, swelling in the extremities and seizures. General: pale, well-developed female appearing anxious; Integumentary: N/A; Head: N/A; Eyes: N/A; ENT: N/A; Cardiovascular: N/A; Respiratory: shortness of breath, coughing, and wheezing; Gastrointestinal: N/A; Genitourinary: N/A; Musculoskeletal: exercise intolerance; Neurological: no headaches; Endocrine: N/A; Hematologic: N/A; Psychologic: N/A.
Vital Signs: BP – 171/94 ; P 122; R 31; T 96.7F; Wt. 145; Ht. 53; BMI 25.7.
Physical Assessment Findings
HEENT: PERRLA, oral cavity without lesions; TM without signs of inflammation; no nystagmus;
Lymph Nodes: N/A;
Lungs: bilateral expiratory wheezes;
Heart: regular rate and rhythm normal S1 and S2;
Abdomen: soft, non-tender, non-distended, no masses;
Rectum: guaiac negative;
Extremities/Pulses: +1 ankle edema on right, no bruising, normal pulses;
Neurologic: A&O X3, cranial nerves intact;
Laboratory and Diagnostic Test Result: Na – 134 (a little bit below the norm); K – 4.9 (normal); Cl – 100 (normal); BUN – 21 (normal); Cr – 1.2 (normal); Glu – 110 (prediabetes condition); ALT – 24 (normal); AST – 27 (normal); Total Chol – 190 (normal); CBC – WNL (normal); Theophylline – 6.2 and Phenytoin – 17 (prove that the patient takes these medications to treat her asthma and control seizures); Chest Xray – Blunting of the right and left costophrenic angles (may be the sign of pleural effusion, lung disease, and lung hyperexpansion); Peak Flow – 75/min (after albuterol – 102/min) (normal); FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% (normal).
- Pleural effusion, not elsewhere classified (J90). The priority of this diagnosis is explained due to the received chest x-ray image where blunting of the right and left costophrenic angles was defined. This problem may be caused by the trauma the patient got several weeks ago. In addition, such symptom as a cough cannot be ignored (Shin, Marone, & Abujudeh, 2016). Still, coughing may not be regular in this disease, and shortness of breath happens when a person tries to breathe in and out frequently.
- Chronic obstructive pulmonary disease, unspecified (J44.9). This disease is defined as one of the primary diagnoses because of the presence of such symptoms as severe wheezing, cough, shortness of breath, and exercise intolerance. In addition to these symptoms, the patient should define if she has some muscle changes and problems to prove this diagnosis (Waschki et al., 2015). Special attention must also be paid to the patient’s weight change during the last several months.
- Unspecified asthma with (acute) exacerbation (J45.901). The patient has already reported on frequent asthma attacks. She got medication-based treatment in the form of Theophylline and Albuterol. Still, it is necessary to know that asthma is a chronic disease characterized by spontaneous remissions (Aaron et al., 2017). Albuterol increases the peak flow up to 102/min. In addition, its systematic use can result in the blood sugar increase. At this point, the patient has 110 as the level of glucose. It is defined as a prediabetes condition. Therefore, this diagnosis cannot be ignored.
Plan of Care
Diagnosis 1: Pleural Effusion
- Diagnosis. To prove pleural effusion as the main cause of respiratory problems, the patient should take a CT scan or ultrasound. The doctor may ask to repeat the blood test in order to check if there is a particular infection in the body. A stethoscope examination should become a daily activity.
- Treatment. Treatment depends on the reason. If it is an infection, antibiotics have to be prescribed. Lifestyle changes can help to treat the disease at its early stage (Shin et al., 2016). The main activities include taking much rest, following a daily schedule, and fresh air walks.
- Education. The patient should be educated about the necessity to record all changes and new symptoms. It is forbidden to change or stop the treatment course without doctor’s permission. It is also possible to avoid traveling to other countries with such condition.
- Counseling. Regular visits to a general practitioner and the discussion of the recent health changes if any may be enough for the patient. Sometimes, it is recommended to address a psychologist to make sure that health changes do not influence her emotional well-being. Family support is important.
Diagnosis 2: COPD
- Diagnosis. Lung tests and CT scan can be offered to prove or disprove this disease. Spirometry is a common diagnostic tool for patients. Oxygen in the blood has to be checked.
- Treatment. Inhaled steroids and ordinary inhalers can be used to make the patient relax and breathe properly. Antibiotics and oxygen therapies should help to deal with infections and stability of the general condition (Centers for Disease Control and Prevention, 2017). Regular exercises and diets have to be followed.
- Education. Even passive smoking can be dangerous for the patient. It is recommended to avoid the places where people smoke. Diet and the quality of food also determine the quality of breathing. Finally, daily diaries should be written.
- Counseling. Regular communication with a family doctor is suggested. Pulmonologist counseling can help the patient. Visits to an immunologist are necessary to take annual flu vaccination and gain control over possible allergies.
Diagnosis 3: Complicated Asthma
- Diagnosis. In addition to a physical examination, the patient may be in need of regulatory peak flow to measure breathing. Blood tests can define if the patient has an allergy or inappropriate reaction to some medications. Lung function tests should regularly be taken to make sure the disease is not progressive.
- Treatment. Pharmacological treatment is usually offered to the patient. Though asthma cannot be cured, it can be managed (World Health Organization, n.d.). Inhalers are used to gain control over seizures. Inflammation may be controlled with the help of antibiotics. Finally, quick-relief medications like ipratropium or beta agonists can help to treat asthma attacks.
- Education. The patient should learn how to use a peak flow meter regularly and make notes. It is not enough to control asthma. It is necessary to share all activities and decisions with a doctor in a proper way, mentioning all details and significant changes. Humidity control and dust avoidance are the obligatory living requirements. Maintenance of a healthy lifestyle is a chance to avoid asthma complications.
- Counseling. Cooperation with pulmonologists is an obligatory task. Sometimes, patients try alternative medicine and address local internal medical centers to use yoga or acupuncture to deal with asthma attacks. Still, the main doctor is a family therapist who leads the patient.
Aaron, S. D., Vandemheen, K. L., FitzGerald, J. M., Ainslie, M., Gupta, S., Lemiere, C., … Mulpuru, S. (2017). Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA, 317(3), 269-279.
Centers for Disease Control and Prevention. (2017). Chronic obstructive pulmonary disease (COPD). Web.
Shin, H., Marone, L., & Abujudeh, H.H. (2016). Pleural collections and emergencies. In H.H. Abujuden (Ed.), Emergency radiology (pp. 96-102). New York, NY: Oxford University Press.
Waschki, B., Kirsten, A., Holz, O., Muller, K. C., Schaper, M., Sack, A. L., … Watz, H. (2015). The role of sustained physical inactivity in the progression of exercise intolerance and muscle depletion in COPD. European Respiratory Journal, 46(59). Web.
World Health Organization. (n.d.). Management of asthma. Web.