Pathophysiology Case Studies
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RESPIRATORY CASE STUDY
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Chief Complaint: “Increased shortness of breath with activity, and sometimes even at rest.” !
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Initial Information
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Date & Time: 7-3-14 @ 2:45 p.m.
Name: JM
Age: 30, DOB 2-18-1984
Gender: F
Marital Status: M
Race: Caucasian
Culture: Northern US, urban
Occupation: Stay at home mom
Health Insurance: BC/BS
Source: Pt, reliable
RF: Allergies in family
Medications: Claritin prn
Allergies: NKDA, questionable seasonal allergies
Tobacco use: No personal use or exposure to second hand smoke currently. Previously tended bar, exposed to smoke there, but that was 4 years ago.
Alcohol Use: Occasional; 4-5 drinks /week
Drug Use: None
History of Present Illness
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Location: …show more content…
Vital Signs: BP 117/62, HR 102, R 24, T 98.1, Pain 0. SpO2 92% on RA.
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Skin: Intact with no lesions present. Warm, dry. No masses, rashes, or discolorations.
No bruising present.
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HEENT: Head: Normocephalic, no lesions or trauma present. Hair clean with normal distribution, no dry scalp noted. No lumps or masses palpated. Temporal arteries palpable bilaterally. Eyes: Glasses on, no drainage noted. Symmetrical, no ptosis, no astigmatism. Follows objects well with eyes, can see all visual fields. Pupils reactive to light, red reflex noted. Conjunctiva clear, sclera white. Ears: Symmetrical, intact. NO lesions or masses noted on pinna. No excessive cerumen or drainage notes. Tympanic membrane intact. No redness noted. Positive whisper test. Nose: Negative for drainage or bleeding. No lesions or masses noted. Septum midline without deviation. NO sinus tenderness with palpation. Throat: Oral mucosa pink, moist, without lesions or petechiae noted. Gag reflex present. Good oral hygiene noted, no halitosis.
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Neck: Trachea midline. No lumps, tenderness, or masses palpated. Neck supple, no stiffness or decreased ROM noted. Thyroid non-tender, no goiter or nodules present. No
JVD noted. …show more content…
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Medications
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busdesonide (Pulmocort) 90µg/inh, take 2 inhalations BID.
Albuterol 90µg/inh, take 1-2 inhalations as needed every 4-6 hours
Peek Flow Meter
Education
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Record PEF twice daily, and how to use meter. To bring log to next visit in 1-2 weeks.
Red zone signifies a medical emergency, take albuterol inhaler asap and seek emergency treatment. Yellow signifies worsening asthma, and albuterol inhaler should be used asap, and follow up with provider if consistently in yellow zone or using rescue inhaler
(albuterol) in less than one month. Green signifies appropriate asthma therapy and continues treatment as usual.
!
Avoid environmental stimulants that may worsen asthma such as smoke, dust, and pollen.
Exposure to cold may also exacerbate symptoms. Perfumes and fragrances may also aggravate symptoms.
!
Following use of inhaled corticosteroid, rinse mouth well to prevent development of candida. !
Emergency plan
!
If PEF showing in red zone, seek medical treatment, and utilize albuterol inhaler.
Keep albuterol inhaler with you at all times. Get albuterol inhaler refilled before
RESPIRATORY CASE STUDY
!
!
Chief Complaint: “Increased shortness of breath with activity, and sometimes even at rest.” !
!
Initial Information
!
!
!
Date & Time: 7-3-14 @ 2:45 p.m.
Name: JM
Age: 30, DOB 2-18-1984
Gender: F
Marital Status: M
Race: Caucasian
Culture: Northern US, urban
Occupation: Stay at home mom
Health Insurance: BC/BS
Source: Pt, reliable
RF: Allergies in family
Medications: Claritin prn
Allergies: NKDA, questionable seasonal allergies
Tobacco use: No personal use or exposure to second hand smoke currently. Previously tended bar, exposed to smoke there, but that was 4 years ago.
Alcohol Use: Occasional; 4-5 drinks /week
Drug Use: None
History of Present Illness
!
Location: …show more content…
Vital Signs: BP 117/62, HR 102, R 24, T 98.1, Pain 0. SpO2 92% on RA.
!
Skin: Intact with no lesions present. Warm, dry. No masses, rashes, or discolorations.
No bruising present.
!
HEENT: Head: Normocephalic, no lesions or trauma present. Hair clean with normal distribution, no dry scalp noted. No lumps or masses palpated. Temporal arteries palpable bilaterally. Eyes: Glasses on, no drainage noted. Symmetrical, no ptosis, no astigmatism. Follows objects well with eyes, can see all visual fields. Pupils reactive to light, red reflex noted. Conjunctiva clear, sclera white. Ears: Symmetrical, intact. NO lesions or masses noted on pinna. No excessive cerumen or drainage notes. Tympanic membrane intact. No redness noted. Positive whisper test. Nose: Negative for drainage or bleeding. No lesions or masses noted. Septum midline without deviation. NO sinus tenderness with palpation. Throat: Oral mucosa pink, moist, without lesions or petechiae noted. Gag reflex present. Good oral hygiene noted, no halitosis.
!
Neck: Trachea midline. No lumps, tenderness, or masses palpated. Neck supple, no stiffness or decreased ROM noted. Thyroid non-tender, no goiter or nodules present. No
JVD noted. …show more content…
!
Medications
!
•
•
•
!
busdesonide (Pulmocort) 90µg/inh, take 2 inhalations BID.
Albuterol 90µg/inh, take 1-2 inhalations as needed every 4-6 hours
Peek Flow Meter
Education
!
Record PEF twice daily, and how to use meter. To bring log to next visit in 1-2 weeks.
Red zone signifies a medical emergency, take albuterol inhaler asap and seek emergency treatment. Yellow signifies worsening asthma, and albuterol inhaler should be used asap, and follow up with provider if consistently in yellow zone or using rescue inhaler
(albuterol) in less than one month. Green signifies appropriate asthma therapy and continues treatment as usual.
!
Avoid environmental stimulants that may worsen asthma such as smoke, dust, and pollen.
Exposure to cold may also exacerbate symptoms. Perfumes and fragrances may also aggravate symptoms.
!
Following use of inhaled corticosteroid, rinse mouth well to prevent development of candida. !
Emergency plan
!
If PEF showing in red zone, seek medical treatment, and utilize albuterol inhaler.
Keep albuterol inhaler with you at all times. Get albuterol inhaler refilled before