Shadow Health Respiratory Assessment Discussion Paper

Posted: December 28th, 2022

Shadow Health Respiratory Assessment Discussion Paper

CC (chief complaint)

“I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.”

HPI: Ms. Jones is a pleasant 28-year-old African American female who came in with symptoms of shortness of breath and wheezing, which she attributed to a near-asthmatic episode she had had two days before. She claims that when she was at her cousin’s place, she was exposed to cats, which caused her asthma symptoms to flare up and worsen. Her wheezes were rated as a 6/10 severity, and her shortness of breath was rated as a 7- 8/10 severity, both of which lasted for five minutes at the time of the occurrence. She didn’t have any chest discomfort or allergy symptoms, which was surprising. She used her albuterol inhaler at that point, and her symptoms began to subside, albeit they did not go away entirely. She reports that she has experienced 10 bouts of wheezing and shortness of breath since then, with one episode occurring every four hours on average since then. Her most recent incident of shortness of breath occurred this morning, just before arriving to the clinic. She expresses concern that her present symptoms are worse by laying down and moving about, and that they are associated with a non-productive cough. Every night, she is awakened by shortness of breath throughout the night. In her complaint, she expresses worry that her present symptoms are starting to hinder her daily activities and that her albuterol inhaler appears to be less helpful than it was before. She claims that her breathing is normal at the present time. Shadow Health Respiratory Assessment Discussion Paper

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Current Medications:

Albuterol 90 mcg/spray 3 puffs every four hours as needed for wheezing

Allergies:

 Penicillin= rash

Cats and dust= runny nose, itchy and swollen eyes and increased asthma symptoms Denies any food or latex allergies

PMHx:

Asthma diagnosed at age 2 ½

Last time hospitalized for asthma was when she was young, has never been intubated Type 2 Diabetes Mellitus diagnosed at age 24

Menarche at age 11

Sexually active and heterosexual, last tested for STIs four years ago, never tested for HIV

Soc Hx:

Tina is a supervisor at Mid-American Copy and Ship, where she has been employed since she was a senior in high school. She is not married and has never become pregnant. She is a non-smoker who drinks alcohol casually with friends once a month. The usage of marijuana between the ages of 18 and 20 is reported. She is a member of a book club, and she likes attending church sessions. She is presently living with her mother and sister at their home Shadow Health Respiratory Assessment Discussion Paper.

Fam Hx:

 

Tina claims that her sister suffers from asthma as well. Denies having a family history of COPD or having had any throat or neck procedures in the past. Her mother is still alive, although she suffers from high cholesterol and hypertension. Her father died in a vehicle accident little over a year ago. Father had elevated cholesterol, high blood pressure, and type 2 diabetes. Her brother is overweight. Tina claims she has no family history of eczema.

ROS:

 

CONSTITUTIONAL: Denies weight loss, fever, chills, weakness or fatigue.

 

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

 

SKIN: Denies rash or itching.

 

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

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RESPIRATORY: Reports shortness of breath, chest tightening, wheezing and non-productive dry cough

 

GASTROINTESTINAL: Denies nausea, vomiting, diarrhea, or abdominal pain.

 

GENITOURINARY: No burning on urination, never been pregnant. Last menstrual period started yesterday.

 

NEUROLOGICAL: Denies headache, Denies change in bowel or bladder control. MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding or bruising. LYMPHATICS: Denies enlarged nodes.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. Denies polyuria or polydipsia.

ALLERGIES: History of asthma, with allergy to cats, dust and penicillin.

O.

Physical exam:

General: Ms. Jones is a pleasant, obese woman in no acute distress. She is alert and oriented and seated upright on exam table. She maintains eye contact through interview.

Respiratory: Chest expansion symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion. Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in poster lower lobes. No crackles. In office spirometry: FVC 3.91 L, FEV1 ratio 80.56%. SpO2: 97%.

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Diagnostic results: None

A.

Differential Diagnoses

 J45. 901-Asthma exacerbation: An asthma exacerbation is characterized by the swelling and inflammation of the airways. The muscles around the airways tense, and the airways generate excessive mucus, prompting the breathing tubes (bronchial tubes) to become narrower and more difficult to breathe (Peters et al., 2020). During an attack, one may experience coughing, wheezing, and difficulty breathing. With timely home treatment, the symptoms of a small asthma exacerbation will subside. In the event of a severe asthma attack that does not improve with home treatment, the situation may quickly escalate to a life-threatening situation (Peters et al., 2020).

P.

 Diagnostics:  Shadow Health Respiratory Assessment Discussion Paper

 

Order PFTs to be completed after exacerbation to have a baseline Obtain oxygen saturation

Rx: Tina to continue with Albuterol inhaler. To be prescribed corticosteroids such as Flovent (44mcg per actuation) 2-4 puffs inhaled BID (Prieto et al., 2017).

 

Education:

 

Tina to be informed on the significance of seeing her asthma doctor on a frequent basis in order to control and treat her asthma problems.

Encourage her to maintain a diary of her asthma symptoms and triggers, which she may bring to her next appointment for evaluation.

Referral/Consults:

Ms. Jones would be referred to an Allergist for further evaluation and treatment.

Follow up:

Follow up appointment would be in 2-4 weeks to review asthma log and make sure medications are helping.

Reference

 

Peters, M. C., Mauger, D., Ross, K. R., Phillips, B., Gaston, B., Cardet, J. C., … & Denlinger, L. C. (2020). Evidence for exacerbation-prone asthma and predictive biomarkers of exacerbation frequency. American journal of respiratory and critical care medicine, 202(7), 973-982.

Prieto Centurion, V., Huang, F., Naureckas, E. T., Camargo, C. J., Charbeneau, J., Joo, M. J., & … Krishnan, J. A. (2017). Confirmatory spirometry for adults hospitalized with a diagnosis of asthma or chronic obstructive pulmonary disease exacerbation. BMC Pulmonary Medicine, 1273. Shadow Health Respiratory Assessment Discussion Paper