2 case studies

CASE STUDY: ASTHMA

RN-BSN, FNP-S

NUR 620 Advanced Physical Assessment

Mervyn M. Dymally School of Nursing

Charles R. Drew University of Medicine and Science

June 30, 2020

CASE STUDY: ASTHMA

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CASE STUDY: ASTHMA

PATIENT INFORMATION: a 25-year-old single woman

CHIEF COMPLAINT: Episodic shortness in breath and chest tightness

HISTORY OF PRESENT ILLNESS: The woman came into the office with complaints about shortness in breath and chest tightness, stating she has had the symptoms on and off for a period of two years but elaborates that the symptoms seems to have worsened lately occurring two to three times monthly. She explains that the symptoms are normally worse during the months of spring and she does to have the exercise-induced or the nocturnal symptoms. Patient stated she was living with a new roommate for the last two months; roommate owns a cat. Patient stated she smokes occasionally. The history of the family reveals that the father had asthma.

ALLERGIES: No known food or drug allergies.

PAST MEDICAL HISTORY: The patient denies any form of previous hospitalizations about the ailment.

PAST SURGICAL HISTORY: no surgical history

FAMILY HISTORY: (+) Asthma

SOCIAL HISTORY: The patient smokes and drinks occasionally

SEXUAL HISTORY: Sexually active

REVIEW OF SYSTEMS:

Constitutional: No weakness, weight change, fever, or pain.

Skin: No rash, changes in pigmentation, dryness, lesions, itching, nail, or hair changes.

Head: (-) headache, limitation of motion, or head injury.

Eyes: No changes in vision, eye pain, glasses or contacts.

Ears: (-) ear pain, tinnitus, ear discharge, or hearing loss.

Nose/Sinuses: No congestion, nasal discharge, bleeding, sneezing, frequent colds. (+) allergies

Oral: no lesions, no bleeding gums.

Throat/Neck: (-) sore throat, hoarseness, dysphagia, no neck pain, no neck swelling. Cardiovascular: (+)chest tightness, no swelling, no heart palpitations.

Respiratory: cough, hemoptysis, (+) shortness of breath.

Gastrointestinal: no heartburn, nausea, vomiting, diarrhea, constipation, changes in appetite, problems swallowing, or rectal bleeding.

Genitourinary: no genital discharge, no burning, no incontinence.

Musculoskeletal: no pain, swelling, broken bones, decreased joint motion or stiffness.

Neurological: no headaches, seizures, loss of consciousness

Endocrine: No polyphagia, polydipsia, polyuria, denies intolerance to heat or cold, no excessive sweating. Hematological: No easy bruising, anemia.

Psychiatric: no feeling of sadness or change in mood, no tension or stress, no insomnia.

PHYSICAL EXAMINATION:

General Survey: Patient is awake, alert, oriented, acute respiratory distress. VS: VS 11.80 HR 84 RR T 98.6 O2 SAT 95% Room air

Skin: pink, warm, moist, intact, no rashes

Head: normocephalic, even hair distribution, no scalp lesions or bald spots, no scalp tenderness

Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation, (+) red orange reflex bilaterally, fundoscopic findings shows no papilledema, no retinal hemorrhages, blood vessels are normal

Ears: no lesions, normal pinna, no tragal tenderness, otoscopy showed non erythematous ear canal, minimal cerumen, no aural discharge, tympanic membrane pearly gray, good cone of light, no bulging or retraction, bilaterally.

Nose/Sinus: nasal septum midline, nostrils patent bilaterally, nasal discharge, pink nasal mucosa, bogginess noted, tenderness over frontal and maxillary sinuses.

Oral/Throat: pink moist oral mucosa, no oral lesion, good dentition, no dental caries,

Neck: supple, no tenderness, no stiffness, carotid pulse with normal upstroke, no bruit appreciated.

Cardiac: reduced pumping efficiency

Lungs: wheezing

Abdomen: flat, no skin discoloration, no visible lesion, flat umbilicus, normoactive bowel sounds, soft, no tenderness on palpation, liver span 7 cm, spleen non palpable, no mass

Genitalia: no complaints.

Extremities: no edema, no deformity, pulses present +2 on all extremities, good range of motion, muscle strength 5/5 on all extremities.

Neurologic: alert and oriented to time, place, situation. Responds appropriately.

ASSESSMENT:

PRIMARY DIAGNOSIS: Asthma

The patient in this case study has asthma. The symptoms and physical study conducted indicates that she experiences shortness in breath, chest pains, mild expiratory wheezing.

PATHOPHYSIOLOGY:

Asthma is defined as a long-term condition that affects the airway causing inflammation and narrowing of the bronchi and bronchioles. During an asthma attack the smooth muscles constrict causing chest tightness and breathing difficulty. Goblet cells are special cells that produce mucous that helps trap substances from entering further into the respiratory system. Air becomes trapped in the alveoli and gas exchange is limited resulting in a decreased amount of oxygen entering the blood and retained carbon dioxide sometimes resulting in respiratory acidosis. Asthma symptoms include breathing difficulty, wheezing, coughing and shortness in breath. It normally varies from person to person in terms of severity. It is important to understand that the ailment cannot be cured. The control of the symptom is the only action that can be taken to contain the disease (Lockey & Ledford, Dennis 2014). Asthma changes from time to time and working with the doctor in the effort of understanding the signs and symptoms is a necessity for the patient. Asthma is a disease that is normally hereditary and the environment that one dwells may lead to the cause of the ailment. The exposure to the different substances and irritates leads to the creation of allergies that triggers symptoms of the ailment. Some of the common triggers that can be identified normally vary from person to person (Lockey & Ledford, Dennis 2014). In this case, the existence of airborne allergens, dust mites, mold spores and cockroach waste particles. Factors such as respiratory infections, physical activities cold are, air pollutants and certain medications leads to the triggering of the symptoms within a patient.

Understanding the risk factors is an important element that the patients need to place under consideration. This is based on the fact that they are likely to affect the asthma patient negatively (Barnes, Drazen, Rennard & Thomson, 2016). Being overweight, smoking, second smoke, and exposure to fumes are factors that likely trigger the ailment within a person.

Understanding the complications that comes with the ailment plays an important part in this case. This enables the patient to be aware of the practices that he or she needs to observe to remain healthy. Apparently, the signs and symptoms of the ailment normally interferes with work, sleep and other activities (Thomson, Rodger & Barnes, 2018). It may affect the social life of the patient. Visits to emergency rooms and hospitalizations are quite common in the schools. Medications prescribed may have negative effects to the patient.

Differential Diagnosis

1. COPD: preventable and treatable disease characterized by airflow limitation that is not fully reversible. It is associated with an abnormal inflammatory response of the lungs to noxious particles or gases. COPD causes cilia dysfunction and oxidative injury. Tobacco smoke is the main risk factor (Epocrates, 2020)

2. Congestive Heart Failure: this is a condition that leads to engorged pulmonary vessels and interstitial pulmonary edema. It leads to a reduction in lung compliance which later results in dyspnea and wheezing. Based on the case study, the patient is having key symptoms that are similar to the symptoms presented by the person diagnosed with congestive heart failure. The symptoms include tightness of the chest and the breathing difficulty which leads to the wheezing sounds upon examination by the physician (Ortal, et al., 2015).

3. Generalized Anxiety Disorder: Chronis condition defined as worry for at least 6 months that causes distress or impairment. Three out of six symptoms are required to make a diagnosis according to the Diagnostic and statistical manual of mental disorders, fifth edition, (DSM-5) (Epocrates, 2020).

Plan

Diagnostic Test

Peak flow: this test is used to measure how well the lungs are pushing air out. The device known as the peak flow meter is used for testing to help in determining the extent of the damage of asthma.

Exhaled nitric oxide test: this procedure involves breathing into the tube that is connected to the machine that measures the amount of nitric oxide breath. Usually, this gas is made normally in the body, nevertheless, the levels of the nitric oxide can be higher if there is inflammation of the airways.

Diagnostic Imaging: Chest x-ray is used to ensure that there is no other condition causing asthma symptoms. Through viewing x-ray of the lung, the cause of asthma can be detected (DerSarkissian, 2019).

Echocardiogram may show reduced or preserved left ventricular ejection fraction.

Lab Test: Serum B-natriuretic peptide may be elevated.

CBC and differential blood test are indicated in the initial workup to exclude other pathologies.

Allergy testing including skin prick testing and immunoassay for allergen-specific igE to determine sensitivity to allergens.

Prognosis

The description of adult asthma has not been successfully carried out. This, therefore, implies that the prognosis of COPD appears to be clear as compared to asthma. There is a low rate of remission and it is limited to the mild cases of asthma disease. Asthma leads to permanent interference with the lung function and the risk of this disease is increased by the presence of the allergens in the environment for example smoke. There is the poor prognosis of lung function, hospitalization, and the death rates for the individual who have a severe condition. Patients who have been in the Intensive Care Units (ICU) and those with brittle asthma are at risk of complications caused by asthma disease (Aftab, et al., 2016).

Therapy process

Short-acting beta-agonists: this medication is used as the quick relief of asthma symptoms for example albuterol, epinephrine, and levalbuterol.

Anticholinergics: These drugs are used to lessen the mucus and helping in the opening of the airways. Such medication includes ipratropium.

Oral corticosteroids: help in lowering the swell of the airways and they include prednisone and methylprednisolone.

There are also preventive long-term medications to help in the prevention of asthma attacks. They help in the reduction of the mucus in the airways. Some of the medications include inhaled corticosteroids that help in long-term control. There are also long-acting beta-agonists that is used to help in the opening of the airways through relaxation of the smooth muscles. A combination of the inhaled medicine also has inhaled corticosteroid and they include long-acting beta-agonists (Pichardo, 2020).

Medical management

It is important to understand that asthma is an ailment that cannot be cured. A unique medical plan to support living with the ailment and preventing asthma attacks is the most important actions in this case. The patient has the duty of ensuring she follows the asthma action plan. This would entail a written plan of medications and the management of the asthma attacks. Getting vaccination from disease such as pneumonia, influenza plays an important part in the management of the ailment based on the severances involved with the ailment (Smith, 2018).

The identification of asthma triggers that are mentioned previously is highly important, it is also equally important to avoid triggers. Warning signs of the attacks such as coughing, shortness in breath and wheezing needs to be given a top priority.

Follow-up care or referral

Following up with a primary care provider on a consistent basis is required to help in preventing asthma exacerbation and the successful process of managing in managing asthma. Follow-up helps in the reduction of the possible hospitalization that is linked to the poor management of the disease (Park et al., 2018). Typically if short acting medications are being used more than two times a week may indicate poorly controlled asthma.

Patient Education

Patients are recommended to monitor recording the peak expiratory flow rate with a monitor at home. Keeping a diary of triggers and asthma attacks will help determine what should be avoided. Getting recommended vaccines, avoiding triggers, and smoking cessation will help reduce the incidence of asthma exacerbation. Wheezing is typically a medical emergency that requires immediate medical treatment.

References

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Barnes, P. J., Drazen, J. M., Rennard, S. I., & Thomson, N. C. (2016). Asthma and COPD: Basic Mechanisms and Clinical Management. London: Elsevier Science.

Lockey, R. F., & Ledford, Dennis F. (2014). Asthma. Oxford University Press.

Patterson, A. V., & Yeager, P. N. (2018). Asthma: Etiology, pathogenesis and treatment. New York: Nova Biomedical Books.

Smith, T. L. (2018). Asthma. New York: Chelsea House Publishers.

Thomson, N. C., Rodger, I. W., & Barnes, P. J. (2018). Asthma [recurso electrónico]: Basic mechanisms and clinical management. Estados Unidos: Academic.

Aftab, R. A., Khan, A. H., Sulaiman, S. A., Ali, I., Hassali, A., & Saleem, F. (2016). An assessment of adherence to asthma medication guidelines: findings from a tertiary care center in the state of Penang, Malaysia. Turk J Med Sci., 46(5), 1300-1305.

Ortal, S., van de Glind, G., Johan, F., Itai, B., Nir, Y., & Iliyan, I. (2015). The role of different aspects of impulsivity as independent risk factors for substance use disorders in patients with ADHD: A review. Curr Drug Abuse Rev., 8(2), 119-133.

DerSarkissian, C. (2019, April 29). Asthma Diagnosis and Tests. Webmd: https://www.webmd.com/asthma/diagnosing-asthma-tests