Download discussion case study and more Cheat Sheet Physiology in PDF only on Docsity!
SHADOW HEALTH RESPIRATORY TINA JONES
Subjective: HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident, she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7- 8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time, she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. She awakens with night- time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2.5 years. She has no recent use of spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her
sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies the current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.
- Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure.
- Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain
- Respiratory : Complaint of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, and tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. Objective: General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on the exam table. She maintains eye contact throughout the interview and examination. - Respiratory: Chest expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion; no dullness. Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior lower lobes. No crackles. In-office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%. Assessment & Diagnosis: Asthma exacerbation
Reports last exacerbation around cats at cousin's house Asked about asthma triggers Reports cat allergy as asthma trigger Reports dust as asthma trigger Denies asthma problems at work Denies asthma problems at home Asked asthma management Reports inhaler Asked about asthma medication Reports albuterol inhaler (Proventil) Reports last inhaler use was three days ago Reports using inhaler no more than 2 times per week Asked about number of puffs when using asthma inhaler Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Asked exacerbation symptoms Reports chest tightness during exacerbation Reports wheezing during exacerbation Reports shortness of breath during exacerbation Denies coughing during exacerbation Denies chest pain during exacerbation Denies painful breathing Asked current breathing
Denies current breathing problem
Priority - High Priority Pro Tip: Uncontrolled blood glucose levels delay or prevent wound healing, and must be addressed to resolve the infection. Unstable blood glucose levels could increase the patient's risk for falls. Evidence - Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose levels. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose levels according to orders. Educate - Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia. Intervene - Diet: Provide the patient a diet without concentrated sweets. Intervene - Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. Planning Pro Tip: First, gauge your patient's current status by checking hydration, vital signs, and perfusion. Measure the patient's blood glucose and provide medication as per the physician's orders. While the patient is in your care, ensure that their meals align with a low glycemic diet, and educate the patient on monitoring her own health status.
7. Obesity Priority - Low Priority Pro Tip: A BMI greater than 30 indicates obesity, but this diagnosis is a low priority at present. Obesity is a long-term health concern that cannot be addressed in a single visit. Evidence - Relevant: "BMI: 31" Evidence Pro Tip: Tina's BMI is 31, which is in the obese range. This numerical evidence is required to establish obesity. Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Planning - Relevant: Educate - Diet: Educate the patient on balanced nutritional intake. Educate - Disease Process: Educate the patient on health risks related to obesity. Educate - Exercise: Educate the patient about the benefits of exercise. Planning Pro Tip: To help your patient
address her obesity, which is often a sensitive topic, use therapeutic communication techniques. First, gain a deep understanding of your patient's situation. Determine her level of health literacy, her feelings and beliefs related to the disease, and the motivation behind their choices. Then educate the patient on the risks of obesity, recommended dietary changes, and healthy exercise.
8. Risk for ineffective respiratory function Priority - Low Priority Pro Tip: When caring for a patient diagnosed with asthma, it's important to be aware of the possibility of emerging respiratory symptoms. However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. Evidence - Relevant: Evidence Pro Tip: Tina's asthma puts her at a general risk for breathing problems. She also reports sometimes needing more puffs to resolve symptoms. Contributing factors are a history of hospitalization and asthma attacks, as well as a sedentary lifestyle and obesity. Planning - Relevant: Planning Pro Tip: Take a general survey of the patient for changes in skin color, and assess respiratory rate, rhythm, depth, and quality to confirm there are no acute breathing issues. Gather data on the patient's breathing status by checking pulse and blood pressure. Auscultate the lungs to listen for abnormal sounds. While the patient is in your care, educate her on the cause and symptoms of shortness of breath so that she can let you know about emerging problems. Empower the patient to take part in her own care by educating her on controlled breathing techniques. 9. Sedentary lifestyle Priority - Low Priority Pro Tip: A patient's sedentary lifestyle compromises her overall health and problems such as diabetes. However, this issue is low priority for a patient with acute pain and a wound that prevents her from walking.
