IHuman Katherine Harris New Case reason for encounter Cough and Shortness of breath, Exams of Nursing

Download IHuman Katherine Harris New Case reason for encounter Cough and Shortness of breath and more Exams Nursing in PDF only on Docsity! IHuman Katherine Harris New Case reason for encounter Cough and Shortness of breath 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 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 2 13. Do you have any pain or other associated symptoms with your cough: No pain, getting out of breath and I think that it maybe related 14. What treatments have you had for your cough: nothing 15. Are you taking any over the counter herbal medications? No, nothing like that 16. Are your immunizations up to date: I assume so Med C Med Vitals Height/weight Skin Temperature Pulse Respiration Blood Pressure Mental Status Spo2 spco eTco2 5' 5" (165.0 cm) - 150 Ib (68.0 kg) (BMI 25.0) Warm, dry 98.6 F 33 hregutar Lv v 24 hregular Vv unlabored Ww Use the sphygmomanometer tab to measure BP 112/84, assessment: normal pulse pressure: normal AandOx4 Lv 94% 3% 40 mmHg Med Documentation This tab only shows documentation for exams performed. Lung Auscultation Left Lung | exp wheeze Vw Right Lung | exp wheeze Vv Cardiac Auscultation Cardiac Ausc | Normal Eye Exams Right Pupil | normal reactive YW Left Pupil | normal reactive Vv Med Documentation This tab only shows documentation for exams performed. -ung Auscultation Left Lung | insp/exp wheeze vw Right Lung | insp/exp wheeze Vv cardiac Auscultation Cardiac Ausc | Normal tye Exams Right Pupil | normal reactive Lv Left Pupil | normal reactive Vv Med <= Rank the diferential diagnoses: Indicate leading (Lead) or alteratve (AK). Then indicate ifthe differential diagnosis represents a must-not-miss (MnM) diagnosis or condition Differential Diagnosis Lead ot | Ma _— eo @ bron, ete oo a puro vl oo a eumoia, bail NOS) oo a Test/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  Med C Interpretation CHEST PALATERAL CLINICAL HISTORY: Cough and Shortness of Breath COMMENTS: PAlLateral view ofthe chest Image shows good x-ay penetration, adequate inspation, No evidence of active pleural or pulmonary parenchymal dsease. Cardiac sihovett is normal in size. The mediastinum and pulmonary vessels appear normal ‘Aorta fs normal n sie and shape, IMPRESSION 1.No evidence of acute pulmonary pathology 2 Normal cardiac sihouete Results The sputum culture and sensitivity (SCS) test is not recommended at this time. 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 © bronchitis, acute © pneumonia, bacterial (NOS) © pneumonia, viral The list above contains only the case author's DDx. 102 Index of Diagnosis Exercises ‘Which of the following are components of the pathophysiology underlying asthma exacerbations? Select all that apply. 1 Both allergens (¢.g., aspirin) and nonallergenic stimuli (e.g.. exercise) may cause bronchoconstriction via products of metabolism and/or inflammatory-cell mediators. Ed Asthmatics exhibit hyperactive bronchi: Bronchoconstriction may result from edema, mucous production, airway smooth-muscle hypertrophy, and/or inflammation. EZ Ainway inflammation is the final common pathway. El 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. Med 2of2 Index of Diagnosis Exercises Which of the following are common asthma triggers and/or asthma comorbidities? Select all that apply. Ed Obesity Ef Rhinitis Ef Chronic sinusitis 3 Hormonal fluctuations, including pregnancy and perimenstrual variability O corp EZ Smoking E@ Respiratory infections Scoring: Your score will be @ if you select more than the number of correct choices. Add COPD 1of3 Index of Plan Exercises What is albuterol’s mechanism of action? © Muscarinic antagonist © Muscarinic agonist © Alpha agonist © Short-acting beta-2 agonist 2of3 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 cclkg of ideal body weight. © 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 cc/kg of ideal body weight even if the 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 Leukotriene antagonists block the action of leukotriene that causes airway edema and inflammation and smooth muscle contraction. Singulair is used to prevent asthma attacks, reduce nasal congestion, and decrease sneezing. itching, and watery eyes and also reduce inflammation in the airways. Report to ER with severe shortness of breath, breathlessness, severe chest pain. PE (physical exam) Vitals: General: Skin/Breast: HEENT & Neck: Cardiovascular: Respiratory: Skin: | Warm, dry lemp: [985 F Pulse: | 88, raythm: regular ‘ae: [left 177184, asseassmant nnrmal_ pulse pressure nermal Respiration: | 24, raythm: regula, effort: unlabored mental status: [Aandi x4 spoz: [94% 116 year old alert arc oriertad, ne acuta distress nates, well crassed elo SOR and cough ‘skin warm and cry Ear: normal external auditory canel, tympanic membrane, transhicent, nar-injacted and oink'sh in colar, no scariing discharge or purulance noted Nace: no cischargo ar polyps, ro edema or tenderness aver the fronta’ or maxllary cinuces regula ale and sayy $1 and $2 auscullated ~mterlar end posterior lung sounes explraterynsplratcry wheezing  Abdomen/ Med C Gastrointestinal: abdomen flat, no pain no tendemess, masses. or pulsations. no guarding or rebound tenderness Genitourinary: Deferred Musculoskeletal: No tenderness or deformity of the back Osteopathic: Deferred Neurological: alert and oriented to person, place, time, and situation Psychological: Deferred ic/Immunologic: No allergies Med 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 a 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 most 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 trigger 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 following the administration of a 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 Med Select test to show results and interpretations chest x-ray PA and lateral albuterol nebulizer treatment trial bedside PEFR or FEV1 Interpretation Reduced FEV1 consistent with acute asthma exacerbation. Select test to show results and interpretations. chest x-ray PA and lateral albuterol nebulizer treatment trial Interpretation bedside PEFR or FEV1 Response is consistent with asthma  21 Med C NR602 Week 3 IHuman Katherine Harris New Case Study - Cough and Shortness of breath