How to address a Respiratory Clinical Case study

How to address a Respiratory Clinical Case study

Patient Initials: __JF_____     Age: ___65 years____            Gender: ___Female____

Subjective Data

Chief Complaint: The patient is a 65-year-old female presenting to the clinic with symptoms of respiratory distress. The patient states to be having severe wheezing, shortness of breath, and coughing at least once daily.

History of Present Illness: The patient presents to the clinic today 10 weeks after being discharged from the hospital following a motor vehicle accident. Two weeks after the accident, she reports to have experienced a post-traumatic seizure and was started on phenytoin. There has been no seizure activity since the initiation of treatment. For the past two months, she reports frequent asthmatic attacks occurring more than four times a week on average. To relieve the symptoms, the patient reports having taken albuterol once today.

PMH/Medical/Surgical History: The patient has a history of periodic asthma attacks since her early 20s. Three years ago, she was diagnosed with mild congestive heart failure that has since been treated with different drugs. She was initially placed on hydrochlorothiazide but later changed to enalapril last year due to a worsening condition. The patient is on a sodium-restricted diet due to her heart condition. She has no history of surgery and reports no food or drug allergies. The patient has been on different medications including Theophylline SR Capsules 300 mg PO BID, Albuterol inhaler PRN, Phenytoin SR capsules 300 mg PO QHS, and HTCZ 50 mg PO BID to manage her CHF and to control seizures.

Significant Family History: There is a family history of hypertension and CCF. The father died at the age of 59 as a result of kidney failure secondary to HTN and the mother at the age of 62 due to CHF.

Social History: She is a non-smoker and drinks no alcohol. She uses caffein, 4 cups of coffee, and 4 diet colas per day.

Review of Symptoms: The patient is positive for shortness of breath, wheezing, coughing, and exercise intolerance. She denies having headaches or seizures based on her past medical history.

Objective Data

Vitals: The patient’s vitals before treatment are as follows: Blood pressure: 171/94 mmHg, Heart rate: 122 beats/minute, Respiratory rate: 31 breaths/minute, Temperature: 96.7 F, Weight: 145 Lbs, Height: 5’3 Meters, BMI: 25.7. The vitals after albuterol breathing treatment are as follows: – BP 134/79 mmHg, HR 80 b/m, RR 18b/m.

Physical Assessment Findings

General: Sick-looking, pale, and appears anxious.

HEENT: The patient denies complaints of headache, visual impairment, or hearing loss. Eyes: PERRLA and no nystagmus noted. The oral cavity does not have any lesions and the tympanic membrane shows no signs of inflammation.

Lymph Nodes: No swelling noted.

Carotids: Smooth, relatively rapid upstroke and smooth gradual downstroke.

Lungs: Bilateral expiratory wheezes are noted.

Heart: Regular rate and rhythm. There are normal S1 and S2 heart sounds.

Abdomen: The abdomen is soft, non-tender, non-distended, and with no masses.

Genital/Pelvic: Assessment of the genitourinary system reveals unremarkable results.

Rectum: The Guaiac test is negative.

Extremities/Pulses: Normal pulses on both extremities. Assessment of the ankles reveals +1 edema.

Neurologic: The patient is alert and oriented to time, place, and person.

Laboratory and Diagnostic Test Results

Laboratory Finding                                                  Reference Value

Na – 134                                                                                              134 – 142 mg/dl
K – 4.9                                                                                                 3.5 – 4.5 mg/dl
Cl – 100                                                                                               98 – 108 mEq/L

BUN – 21                                                                                25 mg/dl
Cr – 1.2                                                                                                0.4 – 1.1 mg/dl
Glu – 110                                                                                62 – 110 mg/dl
ALT – 24                                                                                            5 – 40 U/L
AST – 27                                                                                             5 – 40 U/L
Total Cholesterol – 190                                                                      <265

CBC – WNL

Theophylline – 6.2 5                                                    20 ug/ml

Phenytoin – 17 10                                                         20 ug/ml

The chest X-ray results indicate blunting to the right and left costospheric angles. The peak flow before albuterol is 75/min and after albuterol is 102/min. Other additional diagnostic tests indicate FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%. The FEV1/ FVC ratio indicates mild pulmonary obstruction that is consistent with COPD, asthma, and cystic fibrosis.

Assessment: The three probable diagnoses for the patient using the ICD-10 code classification include:

  1. 41 Moderate persistent asthma with (acute) exacerbation
  2. 43 Acute on chronic combined systolic (congestive) and diastolic (congestive heart failure)
  3. 9 Chronic obstructive pulmonary disease, unspecified

Plan of Care

Moderate persistent asthma with (acute) exacerbation: This is the most probable diagnosis for the patient. The condition presents with a PEF of 40% to 69% and usually requires office or emergency department visits (Castillo et al., 2017). The patient often feels relieved after inhaling short-acting beta 2 agonists. The plan of care for this patient will involve relief of symptoms using albuterol and systemic oral corticosteroids (Castillo et al., 2017). The patient should respond to treatment within 3 hours. Health education should focus on limiting caffeine because it is associated with acute exacerbations. The patient should also limit excess exercise or physical activity alongside exposure to allergens like dust, pollen, and cold (Castillo et al., 2017). Follow-up for the patient will include a plan for one week to assess response to treatment, and further if n response to treatment is observed.

Acute on chronic combined systolic (congestive) and diastolic (congestive heart failure): This condition occurs when the heart does not pump out enough blood leading to symptoms like shortness of breath, activity intolerance, and swelling in the extremities (Chen et al., 2016). The plan of care for the patient will include maintenance of a healthy diet by limiting the intake of sodium, low cholesterol food intake, and low-fat diets (Chen et al., 2016). The patient should continue with enalapril to regulate her blood pressure. Health education will include a discussion of symptoms, when to seek emergency care, and elevation of limbs to prevent edema.

Chronic obstructive pulmonary disease, unspecified: The presence of post-bronchodilator FEV1/FVC less than 70% indicates a limitation in airflow that is observed in patients with COPD (Choi & Rhee, 2020). The plan of care for this patient will involve a prescription with a short-acting bronchodilator inhaler like salbutamol or antimuscarinic inhalers like Tiotropium (Choi & Rhee, 2020). The patient should be able to use them when shortness of breath persists to a maximum of four times a day. Health education should focus on the reduction of stress, deep breathing exercises, and avoiding occupational hazards like pollutants. The follow-up plan should include a one-week re-visit for checkup and appointment with a pulmonologist for further examination.

References

Castillo, J. R., Peters, S. P., & Busse, W. W. (2017). Asthma exacerbations: Pathogenesis, prevention, and treatment. The Journal of Allergy and Clinical Immunology. In Practice, 5(4), 918–927.

https://doi.org/10.1016/j.jaip.2017.05.001

Chen, W., Zheng, L., Li, K., Wang, Q., Liu, G., & Jiang, Q. (2016). A novel and effective method for congestive heart failure detection and quantification using dynamic heart rate variability measurement. PloS One, 11(11), e0165304. https://doi.org/10.1371/journal.pone.0165304

Choi, J. Y., & Rhee, C. K. (2020). Diagnosis and treatment of early chronic obstructive lung disease (COPD). Journal of Clinical Medicine, 9(11), 3426. https://doi.org/10.3390/jcm9113426

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