16-Year-Old Female's Case Study: Cough and Shortness of Breath, Exams of Nursing

Download 16-Year-Old Female's Case Study: Cough and Shortness of Breath and more Exams Nursing in PDF only on Docsity! 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 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 Vitals Height/weight 5' 5° (165.0 cm) - 150 Ib (68.0 kg) (BMI 25.0) Skin Warm, dry Temperature 98.6F Pulse | ge regular Vv v Respiration | 54 regular v unlabored Vv Blood Pressure Use the sphygmomanometer tab to measure BP 112/84, assessment: normal pulse pressure: normal Mental Status |~AandOx4 Vv spo2 94% Spco 3% eTco2 40 mmHg Documentation This tab only shows documentation for exams performed. Lung Auscultation Left Lung | exp wheeze Lv] Right Lung | exp wheeze Lv Cardiac Auscultation Cardiac Ausc | Normal Eye Exams Right Pupil | normal reactive Vv Left Pupil | normal reactive 4 Documentation This tab only shows documentation for exams performed. -ung Auscultation Left Lung | insp/exp wheeze Vv Right Lung | insp/exp wheeze Vv cardiac Auscultation Cardiac Ausc | Normal rye Exams Right Pupil | normal reactive Vv Left Pupil | normal reactive Vv as” Rank the diferent clagnesca: Incleat caging (Lead) or aornatve (i). Then Indlest tho derail dagnects reprosonts © must not mies (MM) dlagnosls or cordon. Differential Biagnosis, Lead art | Mn asta oo g bromaiits, acute oo @ pnoumania, viral oo oo @ poumonia, bacterial (NOS) Saad Eee erie Ea teli) 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 Interpretation CHEST PNLITERAL: CUNICALLNSIORY: Coush and Shoriness of Ureth COMMENTS PalLateral view othe chest af acve ple 3. Card slhouett Ie normal n lee. The medastinum ond puimonsry ALNo oxida of seul pul mary paiclogy ? Normal carding shen 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 cantains anly the case author's DDx. 10f2 Index of Diagnosis Exercises ‘Which of the following are components of the pathophysiology underlying asthma exacerbations? Select all that apply. EZ Both allergens (¢.g., aspirin) and nonallergenic stimuli (e.9., 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 Ainvay inflammation is the final common pathway. Ed 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. 2of2 Index of Diagnosis Exercises Which of the following are common asthma triggers and/or asthma comorbidities? Select all that apply. Ed Obesity EZ Rhinitis Ed Chronic sinusitis 0 Hormonal fluctuations, including pregnancy and perimenstrual variability OJ corp Ed Smoking Ei 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? © Muscarinic antagonist © Muscarinic agonist © Alpha agonist © Short-acting beta-2 agonist 20f3 A50-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. OB. 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. O 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 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) Vitale: General: Shin/Breast: HEENT & Neck: Cardiovascular: Respiratory: skin: | Warm, dry Temp: [986F Pulse: | 88, shythn regular BP: | left: 112/64, assessment normal, pulse pressure: normal Respiration: | 24, shythm: regular, ffort: unlaborod Mental status: | AandO x4 spor: | 94% 1G year old alert and oriented, no acute distress noted, well dressed clo SOB and cough ‘skn warm and dry Er: nammal extemal auditory canal, tympanic membrane, ‘ranslucent ron-in.ectec, and pinkish in color, nc scarring d'scharge or purulence noted Nese: na discharge cr oclyps, no edema or tenderness ovar the frontal or maxillary cinuses regular rate and shythm $1 and 32 auscutated anterior ané posterior lung sounds expiratoryiinspiratary wheezing Abdomen/ Gastrointestinal: Genitourinary: Musculoskeletal: Osteopathic: Neurological: Psychological: ic/Immunologic: abdomen flat, no pain no tendemess, masses, or pulsations. no guarding or rebound tenderness Deferred No tendemess or deformity of the back Deferred alert and oriented to person, place, time, and situation Deferred No allergies Case Summary Learning ob 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 can davelop 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 flowivolume 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