Home > Free Essays > Health & Medicine > Pulmonology > Asthma Patient’s Examination and Care Plan
Rate

Asthma Patient’s Examination and Care Plan Case Study

Exclusively available on IvyPanda Available only on IvyPanda
Updated: Jan 10th, 2021

Patient Initials: L. M., a 65-year-old female.

Subjective Data

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.

Objective Data

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.

Carotids: n/a.

Lungs: bilateral expiratory wheezes.

Heart: rate and rhythm are regular; normal S1 and S2.

Abdomen: non-tender, soft, no masses.

Genital/Pelvic: n/a.

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).

Assessment

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

Asthma

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.

Pleural effusion

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.

Heart failure

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.

References

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.

This case study on Asthma Patient’s Examination and Care Plan was written and submitted by your fellow student. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly.
Removal Request
If you are the copyright owner of this paper and no longer wish to have your work published on IvyPanda.
Request the removal

Need a custom Case Study sample written from scratch by
professional specifically for you?

Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar
Writer online avatar

certified writers online

Cite This paper
Select a referencing style:

Reference

IvyPanda. (2021, January 10). Asthma Patient's Examination and Care Plan. Retrieved from https://ivypanda.com/essays/asthma-patients-examination-and-care-plan/

Work Cited

"Asthma Patient's Examination and Care Plan." IvyPanda, 10 Jan. 2021, ivypanda.com/essays/asthma-patients-examination-and-care-plan/.

1. IvyPanda. "Asthma Patient's Examination and Care Plan." January 10, 2021. https://ivypanda.com/essays/asthma-patients-examination-and-care-plan/.


Bibliography


IvyPanda. "Asthma Patient's Examination and Care Plan." January 10, 2021. https://ivypanda.com/essays/asthma-patients-examination-and-care-plan/.

References

IvyPanda. 2021. "Asthma Patient's Examination and Care Plan." January 10, 2021. https://ivypanda.com/essays/asthma-patients-examination-and-care-plan/.

References

IvyPanda. (2021) 'Asthma Patient's Examination and Care Plan'. 10 January.

More related papers
Psst... Stuck with your
assignment? 😱
Hellen
Online
Psst... Stuck with your assignment? 😱
Do you need an essay to be done?
What type of assignment 📝 do you need?
How many pages (words) do you need? Let's see if we can help you!