Case Study: Katherine Harris - Cough and Shortness of Breath, Exams of Nursing

Download Case Study: Katherine Harris - Cough and Shortness of Breath and more Exams Nursing in PDF only on Docsity! 1 Katherine Harris New Case Study CC: Cough and Shortness of breath 2 DIFFERENT VERSIONS OF THE ANSWER PLUS DISCUSSION AS PER MARKING SCHEME NR602 (EXPERT FEEDBACK) LATEST UPDATE 2023 CONTENTS : ALL QUESTIONS ,OLD-CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL EXAM,EXAMS FEEDBACK,CASE FINDINGS,FEEDBACK,DIFFERENTIAL RANKING ,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding) NR602 Week 3 IHuman Katherine Harris New Case Study - Cough and Shortness of breath VERSION A NR 602 Week 3 IHuman Katherine Harris 16 year old female 5.5 ht, 165cm, 150lb 68.2kg CC: cough and shortness of breath 1. How can I help you today: cough for the last 3 weeks getting worse. SOB when walking to class at school. Stop and take break 1 Med C 2 2. Do you have any other symptoms or concerns we should discuss? No, runny nose congestion for 3 weeks, congestion went away in a week,but cough continue 3. When did you first notice feeling SOB? 3 days now and it’s made me a little scared 4. Does anything make your SOB better or worse? Gets a little better when stop walking and rest for a bit worse at night. 5. Does anything make your cough better or worse: not really, constant, getting worse over past 3 days and seems worse at night 6. Are you coughing up sputum: Nope 7. Do you have any allergies? 8. Are you taking any prescription medications? Nope, still no prescriptions 9. Are you exposed to secondhand smoke: yes, dad. Lost job 3yrs ago, moved to older building with cockroaches, neighbors smoke inside building, I always smell smoke everywhere 10. Do you wheeze: Im not sure 11. Do you now or have you ever smoked or chewed tobacco: Nope 12. Has there been any change in your shortness of breath over time: the last few years, had cough and SOB but it got better after a few days, this time lasting longer Med C Abdomen - palpate abdomen + No pain, tenderness, masses or pulsations « There is no guarding or rebound tenderness + No hepatosplenomegaly « Liver span normal * The spleen is not palpable Extremities - visual inspection extremities + There is no swelling or deformity. * There is no cyanosis, clubbing or edema. Musculoskeletal - inspect/palpate back and spine + No asymmetry or deformity of the back * No tendemess or spasm of the paraspinal muscles ¢ No localized tendemess of the spinous processes or pelvic structures © left arm O right arm Orthostatic available only after you have documented sitting blood press Blood Pressure | 449 1 | 84 Ortho normal Vv format vV Vitals Height/weight 5' 5" (165.0 cm) - 150 Ib (68.0 kg) (BMI 25.0) Skin Warm, dry Temperature 98.6F Pulse | 9g fregutar Respiration | 54 fregular Blood Pressure Use the sphygmomanometer tab to measure BP 112 / 84, assessment: normal pulse pressure: normal Mental Status |AandOx4 v Spo2 94% spco 3% eTco2 40mmHg Documentation This tab only shows documentation for exams performed. Lung Auscultation Left Lung | exp wheeze Vv Right Lung | exp wheeze Vv Cardiac Auscultation Cardiac Ausc | Normal v Eye Exams Right Pupil | normal reactive Vv Left Pupil | normal reactive v Med C Med C Documentation This tab only shows documentation for exams performed. -ung Auscultation Left Lung | insp/exp wheeze iv] Right Lung | insp/exp wheeze Vv tardiac Auscultation Cardiac Ausc | Normal Eye Exams Right Pupil | normal reactive v Left Pupil | normal reactive v  — Atte tet ern eye tame Th ae ema gio eer tooo apn cnn Ditvesntil Dioghoais ead rk | Moat aunes eos broncits acto oe s Preurmirea vw oe s Precimaren trecseria! (1405) oe s st/Diagnosis Association Other Tests asthma chest x-ray PA and lateral complete blood count (CBC) bronchitis, acute chest x-ray PA and lateral pneumonia, viral chest x-ray PA and lateral complete blood count (CBC) pneumonia, bacterial (NOS) chest x-ray PA and lateral complete blood count (CBC) sputum culture and sensitivity (SCS) sputum Gram stain ABUTEROL NEBULIZER TREATMENT TRIAL 4 Interpretation CHEST RALATERAL (CRNA, HASTEREY. Coe el Sermons offre cones FAL tal wee he Une mage sien gecilLeay prema adapta epaate) s atae of act phase petty atmctiymad onan Cora aAouatn 4 casa alin Thy omdlatnate and jutenaly cmasula pga) stad ans trad iene gee Ire Sau 1 fs etm uate pasmenary paltry 2 Mra candi abbas, Results The sputum culture and sensitivity (SCS) test is not recommended at this time. Med C Med C Results The sputum Gram stain test is not recommended at this time. Results The complete blood count (CBC) test is not recommended at this time. What is the correct diagnosis for this patient? © asthma O bronchitis, acute O pneumonia, bacterial (NOS) O pneumonia, viral The list above contains only the case author's DDx. ‘Jof2 Index of Diagnosis Exercises Which of the folowing ere components of the pathophysiology underlying asthina exacecbatiorss? Select ll that apply Bi Both aliergens (¢ g.. aspirin) and nonatergenic stimull (e.g. exercise} may cause bronchoconstiction via products of metabotism andior infammatory-cell mediators i Astimatics exnibet iyperactive bronchi Bronchocanstriction may result fiom edema. mucous production, airway smaoth-muscis hypertrophy. andior inammation Bi Airway infiameation ts te Final common pattwvay, Ed There is 2 netettect of fimited airfiow due to obstruction ‘Scominig’ Your score wit! be 0 if you saiect mitra than the number of carmet chowee. 20f2 Index of Diagnosis Exercises Which of the following are common asthma triggers and/or asthma comorbidities? Select all that apply. @ Obesity EZ Rhinitis @ Chronic sinusitis 1 Hormonal fluctuations, including pregnancy and perimenstrual variability 0 corp @ Smoking @@ Respiratory infections Scoring: Your score will be 0 if you select more than the number of correct choices. Add COPD 1of3 Index of Plan Exercises What is albuterol’s mechanism of action? O Muscarinic antagonist O Muscarinic agonist O Alpha agonist © Short-acting beta-2 agonist 20f3 Index of Plan Exercises 50-year-old male with acute respiratory failure due to a severe asthma exacerbation has been intubated. The respiratory therapist asks for your recommendations for initial ventilator settings. Question: Which of the following do you recommend? O A Use a tidal volume of 10-15 cc/kg of ideal body weight. O B. Maintain a higher respiratory rate (16-20/min) since the patient had rapid, shallow breathing before intubation. © C Use a tidal volume of 6-8 cclkg of ideal body weight even ifthe patient has with mild respiratory acidosis © D.Use a pH of 7.4 as the goal for future ventilator settings © E Maintain a higher respiratory rate (16-20/min) to decrease the CO2 that was likely retained during the exacerbation Med C  PE (physical exam) Vitale: Skins | Ware. ory Temp: [906 F Pulse: | 8, myn regular 88; | att 112/84, aasesamert’ normal, plas pressurs: normal Ruspiration: | 24, mye: regular, atfor, unlabored Montal status: | AandOx4 Spaz | 84% Seaerali | He yaar okt wert and erlontad. co acste distros rated, wall dressed clo SOB wn cough skinyareast: (iq warm and Ory HEENT & Neck: | Gar nomal extemal audhory canal, tympanic membrane. tranakicent non-4njected. and pinkish In color, na scacring dlacharge or purulence noted Cordiovascular’ | recutar rate and rhyfam St and $2 auscuttated Med C  Abdomen/ ; : abdomen flat, no pain no tenderness, masses, or pulsations. no guarding or rebound tenderness Gastrointestinal: Genitourinary: | Deferred Musculoskeletal: | No tenderness or deformity of the back Osteopathic: | Deferred Neurological: | aiert and oriented to person, place, time, and situation Psychological: | Deferred ic/Immunologic: | yo allergies Med C  Med C Case Summary Learning objectives After completing this case, the student should be able to do the following * Construct the differential diagnosis for a pediatric patient with @ cough + Recognize the physical exam findings of asthma + Understand how to diagnose asthma * Develop an appropriate treatment plan for a child with an acute asthma exacerbation Asthma is one of the mast common diagnoses of childhood. Asthma can be characterized with non-specific clinical signs such as cough, dyspnea and wheezing. However a more precise definition of asthma includes airway inflammation, bronchial hyperresponsiveness and airflow obstruction. Asthma is usually diagnosed before age seven in 75% of cases, however it can develop at any age. Patients usually present with one to three of the classic symptoms of asthma which are + Wheeze (high pitched sound, often on exhalation) * Cough + Shortness of breath itis important to note the physical exam can be normal in patients with asthma. The presence of wheezing is suggestive of asthma, but not | specific: Therefore, itis also important to obtain a thorough history which usually indicates a pattern of respiratory symptoms that occur with "exposure to triggers and resolve with tigger avoidance. | Some of the characteristic triggers for the respiratory symptoms of asthma are exercise, cold air, and exposure to inhaled allergens. Some “allergens that commonly trigger asthmatic symptoms are dust mites, mold, furry animals, cockroaches and pollens. Viral infections can also trigger asthma. Studies have also shown evidence of an association between smoke exposure and asthma development. Furthermore, there is an association between asthma and atopic conditions. This is called the ‘atopic march’ which describes the pattern of | onset of different allergic diseases in atopic individuals. Usually this begins with atopic dermatitis in childhood, followed by allergic rhinitis and then asthma in adolescence. ‘To make the diagnosis of asthma; we often use spirometry (in children that can cooperate) which shows airflow limitation that reverses to [normal folowing the administration ofa bronchodilator Pulmonary function testing uses spirometry to measure flow/volume loops to assess the patient's response to the administration of short acting beta agonists such as albuterol. The measurements are compared against predicted normal values for age, height and gender. The three primary measurements in spirometry are: + FEV1. the amount that can be forcefully exhaled in one second * FVC: the total amount of air exhaled starting from a full inhalation to a full forced exhalation * FEV1/FVC: ratio of the two values  20 VERSION B Subjective: CC: Cough, SOB HPI: Katherine is a 16 yo female who presents with cough x 3 weeks and SOB that has developed and worsened over the last 3 days. She notes SOB with minimal exertion such as walking short distances. Pt states cold like symptoms 3 weeks ago as well but have since resolved. Pt notes feeling “wheezes” and chest tightness. Pt denies fevers, chills or sputum with cough. Pt notes rest makes SOB better. Pt states pertinent history bouts of similar SOB over the past 3 years with improvement quickly after. She is exposed to second hand smoke and cockroaches as well. PMH: Eczema Surgical: Denies SH: Housing: With parents in apartment, exposed to cockroaches. Recent Travel: Denies Pets: Denies Smoking: Denies +second hand smoke EtOH: Denies Recreational substance use (past and present): Denies Sexual History: Denies being sexually active. FH: Father- eczema Medications: Denies Allergies: Denies Immunizations: UTD ROS: General: Denies: Usual weight, recent weight change, weakness, fatigue, fever, night sweats, anorexia, malaise Head: Denies: Headache, head injury Eyes: Denies: Vision, glasses/contact lens, date of last eye examination, pain, redness, excessive tearing, double vision (diplopia), floaters (spots in front of eyes), loss of any visual fields, history of glaucoma or cataracts Ears: Denies: Hearing loss, change in hearing, ringing in ears (tinnitus), ear infections Nose and Sinuses: Denies: Frequent colds, nasal stuffiness, hay fever, nosebleeds (epistaxis), sinus trouble, obstruction, discharge, pain, change in ability to smell, sneezing, post-nasal drip, history of nasal polyps 21 Mouth and throat: Denies: Soreness, dryness, pain, ulcers, sore tongue, bleeding gums, pyorrhea, teeth (caries, abscesses, extractions, dentures), sore throat, hoarseness, history of recurrent sore throats or of strep throat or of rheumatic fever Neck: Denies: Lumps, swollen lymph nodes or glands, goiter (thyroid enlargement), pain Pulmonary: +Cough, +trouble breathing (dyspnea), +wheezing, Denies: coughing up blood (hemoptysis), pain with taking a deep breath (pleuritic chest pain), blue discoloration of lips or nailbeds (cyanosis), history of exposure to TB, history of a previous TB skin test and the results if done, recurrent pneumonia, history of environmental exposure Cardiovascular: Denies: Chest pain (including details), dyspnea, paroxysmal nocturnal dyspnea (abbreviated "PND"; patient will describe shortness of breath that improves when he or she sits up and dangles feet off the bed), orthopnea (patient has to sleep on pillows to prevent shortness of breath; quantitate by the number of pillows that the patient sleeps on), edema, palpitations, hypertension, known heart disease, history of a murmur, history of rheumatic fever, syncope or near syncope, pain in posterior calves with walking (claudication), varicosities, thrombophlebitis, history of an abnormal electrocardiogram Gastrointestinal: Denies: Trouble swallowing (dysphagia), pain with swallowing (odynophagia), nausea, vomiting, vomiting blood (hematemesis), food intolerance, indigestion, heartburn, change in appetite, sensation of filling up earlier than usual (early satiety),frequency and character (formed vs. loose) of bowel movements, changes in bowel pattern, rectal bleeding, passing black tarry stools (melena), constipation, diarrhea, abdominal pain, excessive belching or passing of gas, hemorrhoids, jaundice, liver or gallbladder problems, history of hepatitis Objective: Well groomed, well developed female, standing. Pt appears to have labored breathing in distress, using accessory muscles. Appears older than stated age. Vitals: HR: 88 BP 112/82 RR: 26, labored Temp: 98.6 F oral O2: 94% Room Air Ht: 5’5” Wt: 150 lbs Physical Exam: 22 Afebrile, tachypneic with O2 sat of 94%, diffuse bilateral wheezing and decreased breath sounds bilaterally. Test Results: Chest X-ray PA and Lateral: WNL, no evidence of acute pulmonary pathology. Normal cardiac sihouete. Albuterol Nebulizer Treatment Trial: After one treatment, 2.5 mg dose neb albuterol, repeat auscultation of lungs showed clearing bilateral wheezes. Repeat pulse ox 97%. Bedside PEFR or FEV1: FEV1 is 75% of predicted and FEC1/FVC is 76% of predicted. Assessment: Differential Diagnosis: 1 Asthma 2 Pneumonia, bacterial (NOS) 3 Pneumonia, viral 4 Bronchitis, acute Plan: Patient prescribed: Prednisolone, 20 mg BID, for 7 days. Albuterol CFC MDI, 90 ug/puff, 200 puffs per canister. Pt to take 2 puffs prior to exercise and every 4-6 hours as needed for wheezing. Pt to follow up in one week and assess symptoms with provider. Pt educated on how to use MDI as well as educated on medications and side effects. If patient is not seeing relief or control of symptoms, a low dose ICS will be prescribed. Pt agreeable to plan. Pt educated on avoiding allergens. Discussed treatment plan with parents as well who are agreeable to clean home/seek pest control. Parents agreeable to stop smoking plan. Emergency management plan for pt’s asthma discussed and when to seek care. Repeat FEV1 testing planned for follow up visit to establish baseline as well. Pt has no further questions or concerns. 25 Surname 3 The stomach area is round however soft. Inside sounds are not heard. The liver edge is round, somewhat delicate and discernable 2 cm. underneath the privilege costal edge in the mid-clavian line. Both feet show hallux valgus. There is pitting edema of the ankles. Differential Diagnoses List and Ranking: 1. Bronchitis 2. Bacterial Pneumonia 3. Asthma 4. Pyelonephritis 5. Urinary Tract Infection 6. Undiagnosed Cystic Fibrosis Laboratory Tests Ordered: The patient is first found in the emergency room. The accompanying information reflects the underlying tests. CBC: Leukocytes check is 12,500/mm3, 58% neutrophils, 7% groups, 28% lymphocytes, 6% monocytes, 1% eosinophils. Hemoglobin = 19.8 g/dL; Hematocrit = 60%; Platelet check = 320,000/mm3. Chem: Glucose 112 mg/dL (non-fasting); BUN 16 mg/dL, Creatinine 1 mg/dL; Cholesterol 240 mg/dL; Aspartate aminotransferase (AST) 18 U/L, Alanine aminotransferase (ALT) 32 26 Surname 4 U/L, Creatine kinase 72 U/L; Sodium 130 mEq/L, Potassium 4.8 mEq/L; Chloride 90 mE1/L, Bicarbonate 33 mEq/L. ABGs*: PH 7.38, Pa 02 44 mmHg, PaC02 58 mmHg, HCO3 31 mEq/L. Electrocardiogram: Chest x-ray PA and parallel perspectives Sputum culture results are pending. The patient is hospitalized. Spirometry is performed. The stream volume circle and results are as per the following: FEV1 = 0.5L, Predicted = 2.9L, Percent of Predicted = 17% FVC = 1.7L, Predicted = 3.9L, Percent of Predicted = 43% FEV1/FVC = 29% 27 Surname 5