Chief Complaint: Worsening shortness of breath

Chief Complaint: Worsening shortness of breath

Chief Complaint: Worsening shortness of breath

 

A.S. – is a 63-year-old male

Chief Complaint: Worsening shortness of breath

History of Presenting Illness

Onset: When did you start experiencing worsened shortness of breath? “Last week.”

Location: Do you experience pain in any area of your body? “Yes, around the chest region.”

Duration: Does the difficulty in breathing become worse during the day or at night, or is it consistent the whole day? “It becomes worse at night. Sometimes it even becomes very hard to sleep.”

Characteristics: Please describe how it makes you feel. “I feel like I cannot breathe properly, especially when going about my daily activities and I get tired most of the time. My chest is congested, and it hurts so much, especially when I cough.” Is the cough productive? “Yes, with white sputum.” Does your throat hurt? “No.”

Aggravating: What makes the symptoms you have just described worsen? “Cold weather and daily activities.”

Relieving: What about anything that makes the breathing difficulty and chest pain better? “It becomes better when am resting during the day in a warm weather.”

Treatments: Have you taken any drugs or tried any home remedies to relieve your chest pain and shortness of breath? “Yes, I have been using a budesonide inhaler every time I feel like I am short of breath, and salbutamol, every night before I sleep. However, I was given these drugs the last time a visited the hospital and diagnosed with bronchial asthma. The drugs have not been of much help ever since my shortness of breath worsened.”

Severity: Ever since you started experiencing shortness of breath and chest pain, have you been able to go through your daily activities? “No, I have been resting most of the day.” Can you rate the severity of the pain on a scale of 0 to 10, with 0 being very mild and 10 the worst? “10, it really hurts.”

Additional questions:

Have you ever felt the same way before? “Yes, but not as worse as how I have been feeling in the past week.”

Have you been taking all your medications as prescribed? “Yes, but sometimes I may forget and take the drugs 1 or 2 hours late, but I still maintain the dosage and frequency.”

Medical history:

According to your medical records, I can see that you were diagnosed with hypertension about 8 years ago. Is it correct? “Yes.”

You also have a history of gastritis in the past 4 years. You were also diagnosed with bronchial asthma two weeks before your present admission. Is that right? “Yes.”

Social history:

What is your marital status? “I have been married for the past 35 years.” #

Do you have children? “Yes, we were blessed with three kids?”

Where do you live? “We live at a permanent residence near the factory area.”

Do you have any pets? “Yes, a cat among other pets.”

Do you take any recreational drugs such as alcohol, or cigarettes or any other drug? “No. I neither smoke nor take alcohol.”

Family history:

Are your parents alive? “No. My mother died at the age of 79 and my father at the age of 68.”

Are you aware of any serious medical illnesses that they might have suffered from? “None that I can remember.”

What about your siblings? “My brother was diagnosed with bronchial asthma a while back and is currently admitted in the hospital wards receiving treatment.

Drug history:

Which drugs have you been taking to manage your medical condition in the past? I have been using budesonide inhalers for my bronchial asthma, together with salbutamol, once a day. I was also taking 50mg of Telmisartan tablets once every night to manage hypertension and Gliclazide, two tablets twice every day for diabetes.

Are you allergic to any medication? “No. I have never experienced an allergic reaction with the drugs that I have been taking.”

Review of Systems

General: Fever (negative). Change in body weight or appetite (negative). Tired feeling and fatigue (Positive). Sleeping habits and night sweats (Positive). Any Chills. Any changes in ADL’s.

HEENT: Does the patient complain of headaches or change in vision or hearing.

Respiratory: Does the patient experience Chronic cough (Positive), (positive) SOB and white colored sputum. Experiences pain on inhalation and exhalation of air — no sore throat.

Cardiovascular: Painful chest (Positive), check the blood pressure, pulse rate and characteristics.

Gastrointestinal: Negative for abdominal pain. Denies diarrhea, nausea, and vomiting.

Genitourinary: Negative for hematuria, dysuria, discomfort during urination and itchiness.

Musculoskeletal: Complains of lower back and joint pain, a little weakness on the arms and legs, check for joint swelling or arthritis and general muscular weakness.

Neurologic: Observe the patient during the conversation for anxiety, concentration, body balance, forgetfulness, and disorientation.

Physical Examination

Vital signs: BP; HR, RR, T

General appearance: whether mildly dyspneic and thin

Lungs: observe wheezing, breathing characteristic, expiratory phase

Heart: S1 and S2 RRR, heart tones and murmurs

Abdomen: palpitation for tenderness, bowel sounds and check for abdominal bruits

Extremities: conduct a full ROM of all extremities. Check for edema and pulses.

Differential Diagnosis List

Emphysema: It is a health condition that results from the destruction of alveolar walls as a result of imbalanced proteinase enzymatic activities. It is mainly caused by long-term smoking of cigarettes. Sometimes, it might occur as a result genetic reason. The main sign and symptoms of emphysema are worsened shortness of breath, for more than a month or even years (Virchow, 2016). Other symptoms include a longstanding cough, chest pain, wheezing, increased chest size, or a “barrel chest” as a result of abnormally expansion of the lungs, rounded fingertips (clubbing), hypoxia, hypercarbia and cyanosis (Kochhar, 2013).

Chronic Bronchitis: This is a respiratory condition characterized by obstructions of airflow to the lungs as a result of bronchiole edema, hypertrophy of the bronchial smooth muscles, and hyperplasia of goblet cells which produce mucus (Burns, 2013). Some of the clinical presentations of chronic bronchitis include recurrent sputum production, long-term cough, especially during cold nights and early morning, extreme fatigue, slight fever, shortness of breath, and chest discomfort (Poole, Chong, & Cates, 2015).

Chronic dyspnea: This is a respiratory disorder characterized by severe shortness of breath which is persistent for a month or more. However, the severity of the condition varies based on the patients’ physiologic and behavioral responses. The main clinical

presentation of the condition is exertional dyspnea (McComb et al., 2018).). In most cases, chronic dyspnea may lead to asthma, myocardial infarction, heart failure, chronic obstructive pulmonary disease, interstitial lung disease, pneumonia, or psychogenic disorders. Etiologically, dyspnea is a multi-factorial disorder in about one-third of admitted patients in the United States. Most diagnosis, about 66% are made based on the clinical presenting sign and symptoms alone. Most patients with dyspnea complain of shortness of breath, tightness in the chest, wheezing, coughing, and rapid and shallow breathing (Aakre & Iyer, 2015). Environmental factors such as chemical exposures may worsen the condition. Patients diagnosed with dyspnea are advised to avoid precipitating factors such as smoking to help manage the condition and reduce the symptoms.

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Diagnostic Tests

The main diagnostic tests to order, for accurate diagnosis, include:

• PFT’s pre and post-bronchodilator testing for determining response. A chest x-ray is also relevant to determine the presence of infiltrates, peribranchial thickening for bronchitis, and lower lobes increased lung markings (Strunk et al., 2015). Patients with emphysema may show the presence of hyperinflation indicated by a low flat diaphragm and enlarged retrosternal space. Renal and liver test to assess the kidney and liver functions.
• LABS: ABG’s to assess oxygenating CBC for ruling out anemia and polycythemia, CMP for the evaluation of K, Na, Cl. Total protein albumin for the evaluation of the nutritional status of the patient and finally sputum cultures for gram stain evaluation (Gilotra et al., 2017).

 

Problem Statement: Alvin Stafford is a 63 years old man who has been married for about 35 years. He has three kids and lives in a permanent resident near a factory. He was diagnosed with bronchial asthma and given the right medication to manage the condition. Two weeks later, he appeared to the hospital complaining of worsened shortness of breath. He also complained of tightened and painful chest and productive. He is also easily fatigued. Stafford’s most significant active problem (MSAP) is that he was unable to sleep as a result of worsened shortness of breath. His condition worsens at night making it hard for him to sleep. He has been using budesonide inhalers together with salbutamol, once a day to manage his respiratory condition.

Assessment

Alvin Stafford came to the hospital complaining of worsened shortness of breath. He even stated that he was unable to sleep the night before reporting to the hospital. He also confirmed a productive cough, painful and tightened chest in addition to becoming fatigued very easily. Looking at the patient’s age of 63 years old, and the environment that he lives in (around a factory) in addition to his worsened sign and symptoms, it is best if he was hospitalized and treated as an inpatient. His medical history is quite abnormal, given that he was initially diagnosed with bronchial asthma, just a week before his sign and symptoms worsened and given the right medication to manage the condition. The present chief complained might have resulted as a complication of the previous diagnosis.

 

Review of Tests

            During the diagnosis, the patient confirmed symptoms such as wheezing, chest pain, productive cough, fatigue and shortness of breath. The physical examination results on the vital signs were BP: 152/82mmHg, PR:109bpm. His heart and respiratory rates are higher than normal. Other lab test such as renal test showed that the potassium level was at 2.6mmol/L hence, calculated Creatinine clearance was 60ml/min indicating a mid-renal impairment, Red Blood Count (RBC) – (3.8-4.8 x 1012 /l), Neutron- 10.57 ↠‘and Rectus protein- 31.1 ↠‘. All these are indications of acute bronchial asthma.

Final Diagnosis

            For the above diagnostic criteria, the patient has acute bronchial asthma that resulted in chronic dyspnea.

Care Plan

1. Continue using 200mcg budesonide inhalers on a need basis to manage the asthmatic condition together with 200mcg of salbutamol every night (Ferry-Rooney, 2013).
2. Use Albuterol to alleviate the symptoms for better health: Albuterol should be taken 5mg daily starting with a single dose immediately.
3. Also, use Flonase spray 50mcg daily to help reduce the shortness of breath.
4. The patient should avoid aggravating factors such as cold, smoking, over-exercise, or even dusty conditions.
5. The patient should visit the hospital every two weeks once released for follow-up check-ups (Teepe et al., 2015).
6. The patient should strictly adhere to the prescription for a better

Apply information from the iHuman Case Study to answer the following questions:
63 years old with c/o1. Exertional dyspnea
– Productive cough
– Easy fatigability

What is the CC in this case study? What are important questions to ask the patient to formulate the history of present illness and what did the patient tell you?
What components of the physical exam are important to review in this case? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?

the required history questions to ask
the require physical exam to perform
differential diagnoses list
lab test to order

decide if this pt can be treated as out patient or a pt who need to be hospitalised and treat
document any abnormal history or complints on your problem list
assess vital signs and perform the examination that is apprioprate for the type of case
write a concise problem statement about 100 words
start with demographic description of your patient and the chief complaint and the MSAP

order test and review test result and select a final disagnosis
develop a treatment plan