diagnosis

Mr. Dennison, a 40-year-old nonsmoker male with BMI of 28.9 and poorly controlled allergic rhinitis, presents with a productive cough that has increased at night for the past two months. He also has wheezing but no chest pain, shortness of breath, fever, GERD, OSA, or anxiety/stress (Aquifer, 2021).

Chronic cough x2 months worse at night

Inconsistent use of medication

Wheezing

Nonsmoker

Productive cough/clear mucus

Denies fever

Postnasal drip

Denies chest pain

Denies shortness of breath

(Aquifer, 2021)

Mr. Dennison presents to the clinic with a cough that has been present for the previous two months. He reports that his cough is continuous during the day and worsens at night. In addition, the patient mentions hearing a wheezing sound while sleeping. Prior to the patient's continuous cough, he also suffered intense sneezing and congestion for around three to four months, which occasionally generated a clear or yellowish discharge. (Aquifer, 2021).

wheezing

Prominent wheezing throughout lung fields

Chronic cough

Coughing throughout the day

Wheezing and cough exacerbation at nigh time.

Nasal Discharge

Clear to yellow discharge

Congestion

Swollen inferior turbinates

Chronic cough

Coughing throughout the day and worse at night

Nasal drainage for 3 to 4 months

Clear with occasional yellow tinged nasal drainage

Maxillary Sinus 3 to 4 months

No redness noted and non-tender to palpation

Wheezing

Wheezing noted

Incentive spirometry

Spirometry is an easy-to-use device that provides patients with virtual feedback on airflow and peak flow measurement. After 14 days of using incentive spirometry, pulmonary function and respiratory motion have significantly improved, revealing that incentive spirometry is critical for increasing pulmonary function. (Kotani et al., 2017).

Chest x ray

In many clinical contexts, chest X-rays are used as an early diagnostic tool to rule out or observe anomalies in the cardiothoracic region, including lung and heart illnesses. In addition to revealing evidence of illness in the cardiothoracic region, chest x-rays will also reveal signs of infection in this location. (Candemier and Antani 2019)

Peak flow

Peak expiratory flow (PEF) is indicated for monitoring asthmatic patients. It is also utilized as a guiding tool for assessing severity, tracking response to treatment, revealing exacerbations, identifying triggers, and providing objective reason for medication to the patient (Reddle et al, 2018).

Assess and educate the patient on asthma and its triggers, including pollen, dust mites, and chemicals.

Evaluate breath sounds using auscultation.

Environmental management techniques should also be explored, including identifying, and avoiding (indoor or outdoor) allergen exposure at home, work, and school that can exacerbate asthma. Patient education on asthma self-management significantly improved asthma control and encouraged patients to assume responsibility for their own care. By controlling asthma symptoms, patients experience fewer exacerbations and have a lower risk of asthma-related death (Ackley et al, 2019).

The use of short-acting beta-2-adrenergic agonist.

Albuterol (Proventil, Ventolin) 4-6 hours PRN

Short-acting beta2-agonists are classified as bronchodilators. The major funcation is to relax the lining muscles, and they are beneficial for treating acute asthma exacerbations (Ackley et al, 2019).

Pulmicort 90 mcg per actuation 2 puffs inhalation BID

Corticosteroids reduce inflammation in the airways, which increases airflow to the lungs and reduces mucus production in the bronchial tubes (Ackley et al, 2019).

Treatment of allergies with oral antihistamine cetirizine 10mg PO daily

Most asthmatic patients also suffer from recurrent rhinitis. Treatment of allergic rhinitis will reduce the likelihood of exacerbations. (Ackley et al, 2019).

Vaccinate against influenza and Tdap

Prevention is always preferable to searching for a cure. Therefore, it is recommended to stay up to date on immunizations for the prevention of asthma exacerbations and to prevent any causes that can trigger asthma exacerbations (Ackley et al, 2019).