Patient Initials: L. M., a 65-year-old female.
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Chief Complaint: “I suffer from severe wheezing, shortness of breath, and coughing at least once daily.”
HPI: Being discharged from the facility ten weeks ago, the patient reports having shortness of breath, severe wheezing, and coughing. When she speaks, she needs to take breaks and catch her breath. The patient suffers from frequent asthma attacks for two months.
PMH: She has a history of asthma attacks since her early 20s. Taken medications include Albuterol (when necessary) and Theophylline (300 mg PO BID). She was diagnosed with mild congestive heart failure (CHF) three years ago. To control symptoms, the patient takes HTCZ (50 mg PO BID) and Enalapril (5 mg PO BID). The patient follows a sodium restrictive diet. She was hospitalized after a motor vehicle accident (MVA). After two weeks following the MVA, the patient had the post-traumatic seizure. She started to consume Phenytoin (300 mg PO QHS). No known drug or food allergies. No surgery.
Significant Family History: Father deceased at the age of 59 (kidney failure secondary to HTN). The mother deceased at the age of 62 (CHF).
Social History: The patient denies smoking and consuming alcohol, drinks four cups of coffee, and four diet colas daily.
ROS: General: pale, appearing anxious; Integumentary: denies bruising; HEENT: denies problems; Cardiovascular: denies problems; Respiratory: positive for coughing, wheezing, shortness of breath; Gastrointestinal: denies problems; Genitourinary: denies problems; Musculoskeletal: positive for exercise intolerance, denies swelling in the extremities; Neurological: denies a headache; Endocrine: denies problems; Hematologic: denies bruising; Psychologic: denies problems.
Vital Signs: BP: 171/94; HR: 122; RR: 31; T: 96.7 F; Wt.: 145; Ht.: 5’3”; BMI: 25.7.
Physical Assessment Findings
HEENT: PERRLA, no lesions in the oral cavity; TM without inflammation; no nystagmus.
Lymph Nodes: n/a.
Lungs: bilateral expiratory wheezes.
Heart: rate and rhythm are regular; normal S1 and S2.
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Abdomen: non-tender, soft, no masses.
Rectum: guaiac negative.
Extremities/Pulses: +1 ankle edema (right), normal pulses, no bruising.
Neurologic: A&O X3, intact cranial nerves.
Laboratory and Diagnostic Test Results: X-ray results: blunting of the right and left costophrenic angles; FEV1/FVC 60%; peak flow – 75/min, improved after Albuterol (asthma). Total cholesterol – 190 (extremely high).
ICD-10-CM: J45.90 Asthma, unspecified.
ICD-10-CM: J90 Pleural effusion.
ICD-10-CM: I50.30 Diastolic (congestive) heart failure.
Plan of Care
The patient’s diagnosis is asthma associated with wheezing, coughing, and shortness of breath. Spirometry tests (FEV1/FVC) indicate abnormalities in the lung’s capacity (Lee et al., 2015). Pharmacological treatment: The patient should shift to the combination therapy while taking Theophylline (300 mg PO BID) and the salmeterol/fluticasone propionate product (50/250 mg PO BID) (Nie et al., 2013). The patient should continue using Albuterol when needed. Non-pharmacological treatment: The patient should avoid secondhand smoke, allergens, and viral infections. Education: The patient should know that improvements can be unobserved for two weeks, and possible side effects include throat irritation and dry mouth (Nie et al., 2013). Follow-up: It is required in two weeks.
This state is characterized by the presence of fluid in the pleural cavity (Freeman, 2015). X-ray results indicate blunting of costophrenic angles as a sign of pleural effusion. Pharmacological treatment: Amiloride (15 mg daily) should be used to address swelling and decrease high blood pressure (Platz, Jhund, Campbell, & McMurray, 2015). Non-pharmacological treatment: The patient can perform breathing exercises to prevent shortness of breath. Education: The patient should avoid dust and allergens that can provoke coughing. Counseling: It is required to decrease anxiety associated with shortness of breath. Follow-up: It is required in two weeks.
As a chronic condition, congestive heart failure is characterized by the impossibility of a heart to transmit blood and oxygen to organs and tissues (Gandhi, Mosleh, & Myers, 2014). Pharmacological treatment: The patient can start using Captopril (25 mg PO BID) (McMurray et al., 2014). Non-pharmacological treatment: The patient should modify a diet to consume more grains and vegetables. Education: The patient should be informed about possible side effects of using Captopril (loss of appetite, insomnia, nausea). Follow-up: It is required in two weeks.
Freeman, R. K. (2015). Treatment options for patients with recurrent, symptomatic pleural effusions secondary to heart failure. Current Opinion in Pulmonary Medicine, 21(4), 363-367.
Gandhi, S., Mosleh, W., & Myers, R. B. (2014). Hypertonic saline with furosemide for the treatment of acute congestive heart failure: A systematic review and meta-analysis. International Journal of Cardiology, 173(2), 139-145.
Lee, L. A., Yang, S., Kerwin, E., Trivedi, R., Edwards, L. D., & Pascoe, S. (2015). The effect of fluticasone furoate/umeclidinium in adult patients with asthma: A randomized, dose-ranging study. Respiratory Medicine, 109(1), 54-62.
McMurray, J. J., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R.,… Zile, M. R. (2014). Angiotensin-neprilysin inhibition versus enalapril in heart failure. New England Journal of Medicine, 371(11), 993-1004.
Nie, H., Zhang, G., Liu, M., Ding, X., Huang, Y., & Hu, S. (2013). Efficacy of theophylline plus salmeterol/fluticasone propionate combination therapy in patients with asthma. Respiratory Medicine, 107(3), 347-354.
Platz, E., Jhund, P. S., Campbell, R. T., & McMurray, J. J. (2015). Assessment and prevalence of pulmonary edema in contemporary acute heart failure trials: A systematic review. European Journal of Heart Failure, 17(9), 906-916.