Case Study Week #3 iHuman For 60 Year Old Female CC: Shortness Of Breath (CLASS 6550), Quizzes of Nursing

Download Case Study Week #3 iHuman For 60 Year Old Female CC: Shortness Of Breath (CLASS 6550) and more Quizzes Nursing in PDF only on Docsity!

Case Study Week

iHuman For 60 Year Old Female CC:

Shortness Of Breath (CLASS 6550)

Case Study Week #3 iHuman For 60 Year Old Female CC: Shortness Of Breath (CLASS 6550)

iHuman Case Study Report Class: 6550 Week # Reason for Encounter: Shortness of Breath Patient: 60-Year-Old Female Location: Outpatient Clinic with X-ray, ECG, and Laboratory Capabilities

HPI (History of Present Illness):

A 60-year-old female presents to the outpatient clinic with complaints of shortness of breath that began 2 days ago. She reports that the shortness of breath is worsening and occurs both at rest and with minimal exertion. The patient has also noticed a dry cough that started the same day. She denies chest pain but mentions some mild wheezing. No recent fever, chills, or leg swelling. Her shortness of breath is not related to any known allergies or new exposures. She has a history of mild asthma but has been mostly asymptomatic for the past few years. She is anxious and concerned about her symptoms, especially due to a family history of heart disease.

HPI Questions & Answers:

1. Q: When did you first notice the shortness of breath? A: Two days ago.
2. Q: Has the shortness of breath been constant or intermittent? A: It has been worsening and is now occurring both at rest and with minimal exertion.
3. Q: Do you have any chest pain associated with the shortness of breath? A: No, I don’t have chest pain.
4. Q: Have you had any wheezing or coughing? A: Yes, I’ve had a dry cough and some mild wheezing.

5. Q: Is there any swelling in your legs or ankles? A: No, I haven’t noticed any swelling.
6. Q: Have you had any recent fevers or chills? A: No, no fever or chills.
7. Q: Do you have any history of heart disease in your family? A: Yes, my father had a heart attack at the age of 65.
8. Q: Do you have any history of lung disease or asthma? A: I have a history of mild asthma, but I haven’t had symptoms in a few years.
9. Q: Are you currently taking any medications? A: I take a rescue inhaler for asthma, but I don’t use it often.
10. Q: Have you experienced any weight changes recently? A: No, my weight has remained stable.
11. Q: Do you have a history of smoking or exposure to second-hand smoke? A: I smoked about 10 cigarettes a day for 20 years but quit 10 years ago.
12. Q: Have you had any recent hospitalizations or surgeries? A: No, I haven’t been hospitalized recently.
13. Q: Are you experiencing any dizziness or lightheadedness? A: No, I don’t feel dizzy or lightheaded.
14. Q: Do you have a history of hypertension or diabetes? A: I have high blood pressure, and I take medication for it.
15. Q: Have you had any recent travel or exposure to sick individuals? A: No, I haven’t traveled recently, and I haven’t been around sick people.
16. Q: Have you been exposed to any known environmental hazards? A: No, nothing unusual in my environment.
17. Q: Do you feel fatigued or exhausted more than usual? A: Yes, I’ve been feeling more tired than usual, especially with the shortness of breath.
18. Q: How would you describe your daily physical activity level? A: I am generally active and walk for about 30 minutes most days.
19. Q: Do you have any history of blood clots, deep vein thrombosis, or pulmonary embolism? A: No, I have not had any issues with blood clots.
20. Q: Do you have any difficulty breathing when lying flat? A: No, I don’t have trouble breathing when lying down.

21. Q: Have you had any recent changes in your appetite or bowel habits? A: No, everything is normal in that regard.
22. Q: Are you experiencing any headaches? A: No, I haven’t had any headaches.
23. Q: Have you had any difficulty sleeping due to shortness of breath? A: No, I’ve been able to sleep without any major issues.
24. Q: Do you use any over-the-counter medications or herbal remedies? A: No, I only use my inhaler when needed.
25. Q: Is there anything else that might be important for me to know? A: No, that covers everything.

Physical Examination (PE):

● General Appearance: Alert, anxious, but in no acute distress. ● Vital Signs: ○ BP: 145/90 mmHg ○ HR: 88 bpm ○ RR: 20 breaths/min ○ Temperature: 98.6°F (37°C) ○ Oxygen Saturation: 95% on room air ● HEENT: No signs of conjunctival pallor, no cyanosis, no nasal flaring. ● Neck: No jugular venous distention, no lymphadenopathy, no carotid bruits. ● Chest/Lungs: Mild wheezing on auscultation, especially with forced expiration. Diminished breath sounds at the bases. No crackles. ● Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. No peripheral edema. ● Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly. ● Extremities: No cyanosis, clubbing, or edema. ● Neurological: Alert and oriented, no focal deficits.

Differential Diagnosis:

1. Asthma Exacerbation: The patient has a history of mild asthma and reports symptoms of wheezing and shortness of breath.
2. Chronic Obstructive Pulmonary Disease (COPD): A history of smoking could suggest underlying COPD, especially with symptoms of wheezing and shortness of breath.
3. Heart Failure (HF): Shortness of breath with a family history of heart disease and hypertension raises concern for left heart failure.
4. Pulmonary Embolism (PE): Acute onset of shortness of breath without an obvious cause could be a pulmonary embolism, although no clear risk factors are present.
5. Pneumonia: Although no fever is present, a dry cough and shortness of breath could suggest a respiratory infection, such as pneumonia.
6. Acute Coronary Syndrome (ACS): Although chest pain is absent, the family history and age of the patient warrant consideration of possible heart disease.
7. Anxiety or Panic Disorder: The patient is anxious, and symptoms of shortness of breath without a physical cause may be due to anxiety or panic.

Diagnostic Plan:

● Chest X-ray: To rule out pneumonia, lung masses, or signs of heart failure. ● ECG: To evaluate for signs of myocardial ischemia or arrhythmias. ● Complete Blood Count (CBC): To check for signs of infection or anemia. ● Basic Metabolic Panel (BMP): To evaluate kidney function, electrolytes, and glucose. ● Troponin Levels: To rule out myocardial injury. ● BNP (B-type Natriuretic Peptide): To assess for heart failure.

● Pulmonary Function Tests (PFTs): To evaluate for asthma or COPD exacerbation. ● D-dimer: If PE is suspected, though low pre-test probability may rule it out.

Management Plan:

1. Asthma Exacerbation Treatment: ○ Initiate albuterol nebulizer treatments. ○ Consider adding a corticosteroid if the wheezing persists.
2. Heart Failure Evaluation: ○ If BNP is elevated, consider initiating diuretics and ACE inhibitors after confirming diagnosis.
3. ECG and Troponin Evaluation: ○ If any abnormal findings, consider referral to cardiology.
4. Pulmonary Embolism (PE): ○ If D-dimer is elevated, consider CT pulmonary angiography to rule out PE.
5. Patient Education: ○ Discuss the importance of medication adherence for asthma and blood pressure management. ○ Recommend follow-up with a primary care provider and/or cardiologist if heart failure is confirmed.

Final Diagnosis:

● Primary Diagnosis: Asthma exacerbation with underlying hypertension. ● Secondary Diagnosis: Possible mild COPD due to smoking history.

Treatment Plan:

1. Asthma: ○ Prescribe an inhaled corticosteroid (e.g., Fluticasone) for daily use. ○ Continue the rescue inhaler (albuterol) as needed.
2. Hypertension: ○ Continue current antihypertensive medications (e.g., Lisinopril).
3. Follow-up: ○ Schedule a follow-up appointment in 2 weeks or sooner if symptoms worsen.
4. Lifestyle Modifications: ○ Advise weight loss, smoking cessation (if still smoking), and regular exercise.
5. Referral: ○ Refer to a pulmonologist for further evaluation of COPD if symptoms persist.

Outcome:

The patient was given an albuterol nebulizer treatment in the clinic, which provided partial relief of symptoms. The chest X-ray and ECG did not show significant abnormalities. Lab results revealed a mildly elevated BNP, suggesting early heart failure, which will require further evaluation. The patient was educated about her condition and prescribed appropriate medications. She was advised to follow up in 1-2 weeks or sooner if there are worsening symptoms. …………………………………………………………………………………………………………………… ………………. Case Study Week #3 iHuman For 60 Year Old Female CC: Shortness Of Breath (CLASS 6550)