Shortness of breath Ihuman, Study notes of Nursing

Download Shortness of breath Ihuman and more Study notes Nursing in PDF only on Docsity! Laia Nunez iHuman "Cough and Shortness of Breath" NSG 4029-iHuman Case laia Nunez new Case Study Exam (elaborations) CC Sx Do you have any other symptoms or concerns we should discuss? Assoc Sx How can | help you today? shortness of breath when I'm walking to my next class at school. | have to stop and take a break. No, but | did have a runny nose and congestion three weeks ago. The congestion went away in a week but the cough is still there. OLD-CARTS for the HPI @ Asked @ Not asked Graded Approach Question Inform Obtain Clinic Response Onset Location Characteristics Characteristics Characteristics Characteristics Characteristics Aggravating Aggravating When did you first notice feeling short of breath? Has there been any change in your shortness of breath over time? Are you coughing up any sputum? Do you wheeze? Does your chest feel tight or heavy? Do you have any pain or other symptoms associated with your cough? Does anything make your shortness of breath better or worse? This has been happening for three days now and it's made me a little scared! but it got better after a few days so | did not get checked. This time, it’s lasting longer. | also didn't want to stress out my parents because they have to work so much so | never told them. Nope. I'm not sure. Yes, actually, that's the right way to describe it. Tight that is. Just a little bit, No pain, but | am getting out of breath and | think that is maybe related. It gets a little better when I stop walking and rest for a bit. I's a little worse at night Not really, it has been constant Does anything make your cough but has been getting worse over patter or worse? i  Vitals Documentation: @ Pulse: Good, all correct. (FYI actual rate: 88) x Respiration: Incorrect effort, correct is labored. BP: Good, all correct. (FYI actual BP: 112/82) Exam Documentation: Lung Auscultation: Good, all correct. Exams Performed: @ correct Good, you performed 8 key exams for this case: Vitals: Temperature (provided) Vitals: SpO2 (provided) . Vitals: Skin (provided) . Vitals: BP . Vitals: Pulse . Vitals: Respiration . Chest Wall & Lungs: auscultate lungs = visual is jon - anterior & nasterior chest NOOPRWONS You also performed/saw results of additional exams that were not required, but are never inappropriate 1. Vitals: SoCO (provided) 2. Vitals: €TCO2 (provided) @Missing Oops: You missed 5 key exams. They are: 1. HEENT: inspect ears Any patient with upper respiratory symptoms such as cough and congestion must have a thorough examination of the lungs, ears, nos ‘are the components that are a part of the respiratory and ENT system. 2. HEENT: look in ears with otoscope Any patient with upper respiratory symptoms susch as cough and congestion must have a thorough examination of the lungs, ears, nos are the components that are a part of the respiratory and ENT system. 3, HEENT.: inspect nose Any patient with upper respiratory symptoms such as cough and congestion must have a thorough examination of the lungs, ears, nos are the components that are a part of the respiratory and ENT system. 4. HEENT: look up nostrits are the components that are a part of the respiratory an’ 5. HEENT: inspect mouth/pharynx Any patient with upper respiratory symptoms such as cc are the components that are a part of the respiratory an: Based on the information you obtained from you History and Physical exam, select the symptoms or findings that were identified and will help you form a differential diagnosis list. Select no more than 9 items. @ Correct ® Missing X Incorrect Yours Graded Choice Oo ACE-inhibitor therapy Oo Night sweats ® Wheezing oO Syncope oO Difficulty swallowing e History eczema Oo Fever oO Depression @ Cough oO Recent chest trauma @ Shortness of breath oO Foul smelling sputum cough x 3 weeks SOB WORSE OVER PASTS pajateq peweene DAYS, worse at night Chest tightness SOB 3 days ago worse af night. better with rest Related Increased respiratory rate (mild) hx of SOB intarmittent, recent URI Related Decreased oxygen saturation on pulse wheezing. MSAP oximetry Shortness of breath with mild exertion father and mother: eczema Unknown ee Exposure to sec! smoke sh: second hand smoka Rotated ERGY TO UNKNOWN DRUG Unknown re eee ALL coach ches! tightness Related URI 3 weeks ago  YUU Prue) Stes nen wy wre pe Le You have used 98 of a maximum of 120 allowed for this case. Patient L.N is @ 16 year old female who presents t the office with chief complaint of coughing, SOB, chest tightness and nasal congestion. Pt states her cough started 3 weeks ago, her SOB started 3 days ago, She denies fever or night sweats. Upon ‘examination her respiratory rate is elevated and labored , 02 Sat at 94%, Pt lungs sounds were bilateral expiratory wheezing. Pt has a medical history of eczema, and a recent URI infection. Pt denies tobacco use or illicit drug use but states. she has second hand smoke exposure t home with father. ets ae eater old LN is 2 16 yio female who presents with a 3 week history of a dry cough and @ 3 day history of exertional shortness of breath following a week of nasal congestion, On physical exam she is afebrile, tachypnoic with 02 sat of 94%, diffuse bilateral wheezing and decreased breath sounds bilaterally. Past medical history and risk factors are: history of eczema, exposure to second hand smoke and cockroaches in her hame, * Cardiovascular Expert Feedback eel deel eels © Endocrine * Gastrointestinal @ Integumentary LN is @ 16 y/o female who presents with a 3 week Selected Problem C history of a dry cough and a 3 day history of exertional shortness of breath following a week of nasal * Musculoskeletal ec congestion. On physical exam she is afebrile a euclouieat orrect tachypneic with 02 sat of 94%, diffuse bilateral 09 © Integumentary wheezing and decreased breath sounds bilaterally. * Genitourinary/Renal « 'Risariveior Past medical history and risk factors are: history of © Respiratory emery eczema, exposure to second hand smoke and cockroaches in her home * Hematologic Discussion: * Lymphatic * Immune Respiratory: The presence of « Complete your differential agnosis selection. Select diagnoses trom categories below and add to differential on right BSAC Tbe aC ie ber mele le erty Lotte mall tel g @ astm ‘ — Selected Differential Diagnoses @ bronchitis, acute @ correct e tory Infection (URS) Good, all correc! © preurenis: ie a @Missing DP ienewnotte, bacterial (NOS) You wore missing 0 diseases that were specified by the case author @ pmeumonia, atypical @ pertussis 1 of 2 index of Diagnosis Exercises Which of the following are components of the pathophysiology underlying asthma exacerbations? Select all that apply. ® Correct ® Missing X Incorrect Yours Graded Choice Both allergens (e.g., aspirin) and nonallergenic stimuli (e.g., exercise) may cause bronchoconstriction via products of metabolism and/or inflammatory-cell mediators. Asthmatics exhibit hyperactive bronchi: Bronchoconstriction may result from edema, mucous production, airway smooth-muscle hypertrophy, and/or inflammation. Airway inflammation is the final common pathway. There is a net effect of limited airflow due to obstruction. Scoring: Your score will be 0 if you select more than the number of correct choices. 20f2 Index of Diagnosis Exercises Which of the following are common asthma triggers and/or asthma comorbidities? Select all that apply. @ Correct ® Missing X Incorrect Yours Graded Choice BSESBSBEEA Obesity Rhinitis Chronic sinusitis Hormonal fluctuations, including pregnancy and perimenstrual variability COPD Smoking Respiratory infections Scoring: Your score will be 0 if you select more than the number of correct choices. Picase enter your assessmentmanagament pian or SOAP note below. Patient L.N is a 16-year-old female who presents t the office with a [chief compiaint of coughing, SOB, chest tightness, and nasal congestion, Pt states her cough started 3 weeks ago, and her ‘SOB started 3 days ago. She denies fever or night sweats. Upon the diagnosis for this patient is asthma ICD Code 10 is J45.41. The treatment option for this patient will be ICS, this patient can be prescribed Fluticasone 100 mog /day to start and albuterol q 4-5 PRN for rescue treatment. Albuterol is a bronchodilator. and bronchodilators are non-steroid medications that help open up your ainways by relaxing small muscles that tighten them. [American Academy of allergy asthma and immunology (2020). The differential diagnosis for this patient includes URI, Pertussis, and pneumonia. Pneumonia was ruled out due to chest Xray not ‘showing infiltrates. Watkins and Lemonovich (2020) explained that ‘an infittrate on hung imaging, usually, chest radiography ts required: ate rs Since Laia improved with one treatment of nebulized albuterol, we can send Laia home with an albuterol inhaler to use at home. We would advise her to use il up to every four hours as needed for wheezing, Due to the seventy of Laia's symptoms, we would also send her home with a five day course of oral glucocorticoids. A short ‘course of oral glucocorticoids reduces the likelihced of a repeat severe exacerbation. We would educate Laia and her mother about the symptoms of a xacerbation such as increasing shortness ot worsening asthma e: breath, use of accessory muscies for breathing and increased cough and wheezing. We would educate Laia and her mother about the proper use of the albuterol inhaler, We would also help to create an asthma action plan for Lais which provides specific instructions on dally management of her asthma, what to do for an acuts exacorbation and when to go to the emergency room, To see an astima action pian. click here Finally, we would ask Laia to return to the clinic or check in by phone in 24-48 hours to monitor for improvement of her symptoms.  for the diagnosis of CAP; therefore, the test should be performed in patients with clinically suspected CAP. Another differential diagnosis that was ruled out is Bordetella pertussis, PCR was negative which ruled out this diagnosis. Lastly, asthma was chosen as her diagnosis due to her FEV1 score and improvement once nebulizer treatment was given. Education is also important, teach patient to avoid triggers such as dust mites, mold, and cockroaches. Educate patient to avoid second-hand smoke because it can trigger asthma. Secondhand smoke is a well-known asthma trigger. Secondhand smoke can harm the lungs, cause long-term breathing problems, and make existing breathing problems worse KidsHealth (2020). Educate the patient to follow up if she uses a rescue inhaler more than 4-6 times a day. References Inhaled asthma medications TTR | AAAAI. (n.d.). The American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/conditions-and-treatments/library/asthma- library/inhaled-asthma-medications