Respiratory Clinical Case and Care Plan Creation
Background Patient Initials _A. B._____
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Subjective Data: The patient suffers from shortness of breath and the associated respiratory issues (wheezing). Chief Complaint: “severe wheezing, shortness of breath and coughing at least once daily.” History of Present Illness: The patient has been experiencing regular asthma attacks over the past few months (four or more times per week). Two weeks ago the patient had an MVA issue, which was followed by a posttraumatic seizure. After anticonvulsant phenytoin had been administered to the patient, seizures stopped. PMH/Medical/Surgical History: The patient has been suffering from regular asthma attacks since her early 20s. Three years ago, the patient had mild congestive heart failure. A sodium restrictive diet was prescribed as an intervention. A year ago, the patient had a CHF, which was addressed with enalapril. Significant Family History: The patient’s father died of kidney failure secondary to HTN at the age of 59. The patient’s mother died of CHF at 62. Social History: The patient does not smoke, nor does she consume alcohol. She drinks four cups of coffee per day.
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Review of Symptoms Objective Data: Vital Signs: BP 171/94 ; P ; R ; T ; Wt. 145; Ht. 5’3” ; BMI. Physical Assessment Findings: chest X-ray results: right and left costophrenic angles HEENT: PERRLA, no evident signs of TM inflammation, no lesions in the oral cavity, no nystagmus. Lymph Nodes: no swelling Carotids: regular S1 and S2 rhythm Lungs: bilateral expiratory wheezes can be observed
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Heart: BP 134/79, HR 80, RR 18 Abdomen: no masses; soft, non-tender Genital/Pelvic: pale Rectum: Guaiac negative Extremities/Pulses: ankle edema Neurologic: A&O X3, cranial nerves intact Laboratory and Diagnostic Test Results: (Include result and interpretation.)
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Na – 134 (slightly below normal) K – 4.9 (normal) Cl – 100 (normal) BUN – 21 (slightly above normal) Cr – 1.2 (slightly above normal) Glu – 110 (above normal) ALT – 24 (normal) AST – 27 (normal) Total Chol – 190 (normal) CBC – WNL (complete blood count: within normal limit) Theophylline – 6.2 (normal) Phenytoin – 17 (normal) Peak Flow – 75/min; after albuterol – 102/min (low) Positive for the diagnosis FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% (severe obstruction) Chest Xray – Blunting of the right and left costophrenic angles (possible pleural effusion) Assessment ICD-10-CM Diagnosis Code J44.1: Chronic obstructive pulmonary disease with (acute) exacerbation The difficulty that the patient has with breathing can be viewed as the primary symptom of chronic obstructive pulmonary disease that is likely to exacerbate at a rather rapid pace. The fact that the patient has asthma serves as proof of the accuracy of the diagnosis. ICD-10-CM Diagnosis Code J44.9: Chronic obstructive pulmonary disease, unspecified The shortness of breath experienced by the patient may also indicate the development of the unspecified chronic obstructive pulmonary disease. Wheezing and chest tightness that the patient has been experiencing should be considered the primary indicators of the disease. ICD-10-CM Diagnosis Code J43.9: Emphysema, unspecified The inflammation of alveoli, which is caused by emphysema, can also be considered the reason for the patient to have the symptoms mentioned above. Thus, emphysema may be the third possible diagnosis. However, the fact that the patient does not smoke makes the identified diagnosis not as plausible as the other two. Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided). Diagnosis A Diagnostic The patient may require lung ventilation so that the difficulties with breathing should not exacerbate. Arterial blood gas analysis (ABGA) will have to be considered as the means of detecting the issue (Kumar, Khilnani, Banga, & Sharma, 2013). Therapeutic Controlled oxygen therapy (2 L/min) should be viewed as the primary therapeutic strategy (Kumar et al., 2013). Education The patient must be provided with extensive information on the essential symptoms and the medicine that she must take to avoid further health complications. Counseling It will be necessary to provide the patient with extensive support and counseling so that she could become aware of her disorder and, therefore, be able to manage it independently. Diagnosis B Diagnostic Apart from AGS, one should consider the use of a CT scan, as well as spirometry and X-rays as the means of detecting the presence of the disease. The use of a CT scan can be deemed as less harmful than X-rays. Therapeutic Ventilation should be administered to the patient so that the breathing issues should be addressed. The identified procedure, performed with the help of bronchodilators, will help relax the muscles around the lungs and, thus, release the tension. Furthermore, corticosteroids may have to be provided. Education Apart from the essential information about the disease and the treatment options, the patient must be provided with information about contacting the local healthcare professionals (HCPs). Counseling Counseling may cover the issues such as education opportunities, treatment options, etc. Diagnosis C Diagnostic Pulmonary function tests should be viewed as the first step toward diagnosing the issue. Therapeutic The use of inhalers, medicine, and, possibly, surgery (in case the rest of the strategies will prove inefficient) will have to be considered. Education The patient must be provided with extensive information on managing the breath shortness issue. Furthermore, the information for contacting the nearby HCP will have to be offered. Counseling The counseling process will have to include detailed information about the treatment options (i.e., medications, possible surgery, etc.) and the tools for the independent management of the issue (National Health, Lung, and Blood Institute, 2017). References Kumar, S., Khilnani, G. C., Banga, A., & Sharma, S. K. (2013). Predictors of requirement of mechanical ventilation in patients with chronic obstructive pulmonary disease with acute respiratory failure. Lung India, 30(3), 178-182. Web. National Health, Lung, and Blood Institute. (2017). What is COPD? Web.