Case Study Exam on Respiratory Symptoms, Exams of Nursing

Download Case Study Exam on Respiratory Symptoms and more Exams Nursing in PDF only on Docsity! 1 NSG 4029-iHuman Case laia Nunez new Case Study Exam (elaborations) e@ CC Sx How can | help you today? Do you have any other @ Assoc Sx | symptoms or concerns we should discuss? OLD-CARTS for the HPI @ Asked @ Not asked Graded Approach Question Onset When did you first notice feeling shortness of breath when I'm walking to my next class at school. | have to stop and take a break. No, but | did have a runny nose. and congestion three weeks ago. The congestion went away in a week but the cough is still there. Inform Obtain Clinic Response This has been happening for three days now and it's made ? shorkor breath? me a little scared! Location but it got better after a few days Has there been any change in _so | did not get checked. This @ = Characteristics your shortness of breath over time, it's lasting longer. | also time? didn't want to stress out my parents because they have to work so much so | never told them. 5 3 Are you coughing up any e Characteristics sputum? Nope. @ = Characteristics Do you wheeze? I'm not sure. ; Yes, actually, that's the right way @ = Characteristics re | : pean chesttieel.tightior to describe it. Tight that is. Just wy! alittle bit, Do you have any pain or other —_— No pain, but | am getting out of @ Characteristics symptoms associated with your — breath and | think that is maybe cough? related. Does anything make your It gets a little better when | stop @ = Aggravating shortness of breath better or walking and rest for a bit. It's a worse? little worse at night. Not really, it has been constant @ = Aggravating Does anything make your cough _ but has been getting worse over better or worse? the nast three davs and seems Vitals Documentation: @ Pulse: Good, all correct. (FYI actual rate: 88) X Respiration: Incorrect effort, correct is labored. @ BP: Good, all correct. (FYI actual BP: 112/82) Exam Documentation: @Lung Auscultation: Good, all correct. Exams Performed: @ correct Good, you performed 8 key exams for this case: . Vitals: Temperature (provided) . Vitals: SpO2 (provided) . Vitals: Skin (provided) Vitals: BP . Vitals: Pulse . Vitals: Respiration . Chest Wall & Lungs: auscultate lungs NOOPRWONA You also performedisaw results of additional exams that were not required, but are never inappropriate. 1. Vitals: SpCO (provided) 2. Vitals: eTCO2 (provided) @Missing Oops. You missed 5 key exams. They are: 1. HEENT: inspect ears Any patient with upper respiratory symptoms such as cough and congestion must have a thorough examination of the lungs, ears, nos are the components that are a part of the respiratory and ENT system. 2. HEENT: look in ears with otoscope Any patient with upper respiratory symptoms such as cough and congestion must have a thorough examination of the lungs, ears, nos are the components that are a part of the respiratory and ENT system. 3. HEENT: inspect nose Any patient with upper respiratory symptoms such as cough and congestion must have a thorough examination of the lungs, ears, nos are the components that are a part of the respiratory and ENT system. 4. HEENT: look up nostrils are the components that are a part ot the respiratory an: 5. HEENT: inspect mouth/pharynx Any patient with upper respiratory symptoms such as cc are the components that are a part of the respiratory an Based on the information you obtained from you History and Physical exam, select the symptoms or findings that were identified and will help you form a differential diagnosis list. Select no more than 9 items. ®@ Correct ® Missing X Incorrect Yours Graded Choice oO ACE- inhibitor therapy oO Night sweats @ Wheezing oO Syncope oO Difficulty swallowing @ History eczema oO Fever | Depression @ Cough oO Recent chest trauma e Shortness of breath oO Foul smelling sputum cough x 3 weeks SOB WORSE OVER PAST 3 DAYS, worse at night Related ‘SOB 3 days ago worse at night, better with rest Related hx of SOB intermittent, recent URI Related wheezing, MsAP father and mother- eczema Unknown sh: second hand smoke Related ALLERGY TO UNKNOWN DRUG Unknown chest tightness Related Wheezing Chest tightness Increased respiratory rate (mild) Decreased oxygen saturation on pulse oximetry Shortness of breath with mild exertion Exposure to second hand smoke History of eczema Cough URI 3 weeks ago MSAP RELATED RELATED RELATED RELATED RELATED UNKNOWN RELATED RELATED  Write your prloviettt Steerer mT Wie space vEIUW. You have used 98 of a maximum of 120 allowed for this case. Patient L.N is a 16 year old female who presents t the office with a chief complaint of coughing, SOB, chest tightness and nasal congestion. Pt states her cough started 3 weeks ago, her SOB started 3 days ago. She denies fever or night sweats. Upon examination her respiratory rate is elevated and labored , 02 Sat at 94%. Pt lungs sounds were bilateral expiratory wheezing. Pt has a medical history of eczema, and a recent URI infection. Pt denies tobacco use or illicit drug use but states she has second hand smoke exposure t home with father. eee ae |Log Lis a 16 ylo female who presents with a 3 week history of a dry cough and a 3 day history of exertional shortness of breath following a week of nasal congestion. On physical exam she is afebrile, tachypneic with 02 sat of 94%, diffuse bilateral wheezing and decreased breath sounds bilaterally. Past medical history and risk factors are: history of eczema, exposure to second hand smoke and cockroaches in her home. * Cardiovascular * Endocrine * Gastrointestinal @ Integumentary eee eel me Cid Expert Feedback LN is a 16 y/o female who presents with a 3 week Selected Problem C history of a dry cough and a 3 day history of exertional shortness of breath following a week of nasal + Musculoskeletal ec t congestion. On physical exam she is afebrile, * Neurological ORES tachypneic with O2 sat of 94%, diffuse bilateral « Integumentary wheezing and decreased breath sounds bilaterally. * Genitourinary/Renal R ti Past medical history and risk factors are: history of @ Respiratory = eecrinom eczema, exposure to second hand smoke and ; cockroaches in her home. + Hematologic Discussion: Lymphatic * Immune Respiratory: The presence of ¢ Sellen GA oeantredtnina eliocinee Complete your differential diagnosis selection. Select diagnoses from categories below and add to differential on right. Student Differential Diagnoses aoa T1011 a thr - . . @ asthma Selected Differential Diagnoses @ bronchitis, acute @ correct @ upper respiratory infection (URI) Good, all correct. © pneumonia, viral @Missing @ pneumonia, bacterial (NOS) You were missing 0 diseases that were specified by the case author. @ pneumonia, atypical @ pertussis 1of2 Index of Diagnosis Exercises Which of the following are components of the pathophysiology underlying asthma exacerbations? Select all that apply. @ Correct ® Missing X Incorrect Yours Graded Choice e e e e Both allergens (e.g., aspirin) and nonallergenic stimuli (e.g., exercise) may cause bronchoconstriction via products of metabolism and/or inflammatory-cell mediators. Asthmatics exhibit hyperactive bronchi: Bronchoconstriction may result from edema, mucous production, airway smooth-muscle hypertrophy, and/or inflammation. Airway inflammation is the final common pathway. 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. 2o0f2 Index of Diagnosis Exercises Which of the following are common asthma triggers and/or asthma comorbidities? Select all that apply. @ Correct ® Missing X Incorrect Yours Graded Choice BESBSBEBEEH eeeeeee Obesity Rhinitis Chronic sinusitis Hormonal fluctuations, including pregnancy and perimenstrual variability COPD Smoking Respiratory infections Scoring: Your score will be 0 if you select more than the number of correct choices. Please enter your assessment/management plan or SOAP note below. Patient L.N is a 16-year-old female who presents t the office with a chief complaint of coughing, SOB, chest tightness, and nasal congestion. Pt states her cough started 3 weeks ago, and her ‘SOB started 3 days ago. She denies fever or night sweats. Upon examination her respiratory rate is elevated and labored, 02 Sat at 94%. Pt lung sounds were bilateral expiratory wheezing. Pthas a medical history of eczema and a recent URI infection. Pt denies tobacco use or illicit drug use but states she has second-hand ‘smoke exposure at home from her father. Due to the assessment, the diagnosis for this patient is asthma ICD Code 10 is J45.41. The treatment option for this patient will be ICS, this patient can be prescribed Fluticasone 100 mcg /day to start and albuterol q 4.6 PRN for rescue treatment. Albuterol is a bronchodilator, and bronchodilators are non-steroid medications that help open up your airways by relaxing small muscles that tighten them. ‘American Academy of allergy asthma and immunology (2020). The differential diagnosis for this patient includes URI, Pertussis, and pneumonia. Pneumonia was ruled out due to chest Xray not showing infiltrates. Watkins and Lemonovich (2020) explained that an infiltrate on lung imaging, usually, chest radiography is required elas eel lel Since Laia improved with one treatment of nebulized albuterol, we can send Laia home with an albuterol inhaler to use at home. We would advise her to use it up to every four hours as needed for wheezing. Due to the severity of Laia's symptoms, we would also send her home with a five day course of oral glucocorticoids. A short course of oral glucocorticoids reduces the likelihood of a repeat severe exacerbation. We would educate Laia and her mother about the symptoms of a worsening asthma exacerbation such as increasing shortness of breath, use of accessory muscles for breathing and increased cough and wheezing. We would educate Laia and her mother about the proper use of the albuterol inhaler. We would also help to create an asthma action plan for Laia which provides specific instructions on daily management of her asthma, what to do for an acute exacerbation and when to go to the emergency room. Tose an asthma action plan, click here. Finally, we would ask Laia to return to the clinic or check in by phone in 24-48 hours to monitor for improvement of her symptoms.  for the diagnosis of CAP; therefore, the test should be performed in patients with clinically suspected CAP. Another differential diagnosis that was ruled out is Bordetella pertussis, PCR was negative which ruled out this diagnosis. Lastly, asthma was chosen as her diagnosis due to her FEV1 score and improvement once nebulizer treatment was given. Education is also important, teach patient to avoid triggers such as dust mites, mold, and cockroaches. Educate patient to avoid second-hand smoke because it can trigger asthma. Secondhand smoke is a well-known asthma trigger. Secondhand smoke can harm the lungs, cause long-term breathing problems, and make existing breathing problems worse KidsHealth (2020). Educate the patient to follow up if she uses a rescue inhaler more than 4-6 times a day. References Inhaled asthma medications TTR | AAAAI. (n.d.). The American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/conditions-and-treatments/library/asthma- library/inhaled-asthma-medications