iHuman Case Study - Alvin Stafford
iHuman Case Study - Alvin Stafford
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iHuman ... [Show More] Case Study - Alvin Stafford
A.S. - is a 63-year-old male
Chief Complaint: Worsening shortness of breath
Associated Sx/Sx Characteristics:
When did you start experiencing worsened shortness of breath? “Last week.”
Do you experience pain in any area of your body? “Yes, around the chest region.”
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.”
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.”
What makes the symptoms you have just describe worsen? “Cold weather and daily activities.”
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.”
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 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.
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.”
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.”
PMH
According to your medical records, I can see that you were diagnosed with hypertension about 8 years ago. Is it correct?
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?
SH
What is your marital status?
Do you have children?
Where do you live?
Do you have any pets?
Do you take any recreational drugs such as alcohol, or cigarettes or any other drug?
FH
Are your parents alive?
How old are they?
Are you aware of any serious medical illnesses that they might have suffered from?
What about your siblings?
MH
Which drugs have you been taking to manage your medical condition in the past?
Are you allergic to any medication?
ROS
Tell me if you have any problems with: high fever, change in appetite or weight, fatigue, sleep, night sweats or chills?
Do you have any problems with: headaches or, change in hearing or vision?
Do you have any problems with: Chronic cough, SOB, white colored sputum, pain upon inspiration or expiration and wheezing?
Do you experience any of the following symptoms: Chest pain or heart racing or missing beats?
Do you experience any of the following: abdominal pain, nausea and vomiting and diarrhea ?
Do you have problems with: painful urination, blood in urine, itchiness or discomfort of genitalia?
Do you experience any of the following: back and joint pain? joint swelling or arthritis, arm or leg weakness, or general body weakness?
Have you ever had any of the following symptoms: seizures, anxiety disorder, inability to concentrate, forgetfulness or difficulty with balance?
The patient has no issues with changes in vision, or headache, nose, throat or ear problems.
No problem with nausea and vomiting.
No changes in stool color or defecation pattern but complains about burning sensation while defecating at least twice a month.
Worsened shortness of breath/ inability to sleep MSAP
Productive cough Related
Fatigue Related
Tight chest Related
Painful inhalation and exhalation Related
Sore throat Related
Lower back pains Related
Other muscle aches Unknown
Family medical history of both parents Unknown
Physical Examination
For the patient’s physical examination, it is important to review the primary vital signs such as blood pressure, body temperature, respiratory rate and heart rate. The general appearance of the patient is also essential. The patient’s lungs must also be examined to observe any signs of wheezing, breathing characteristic and expiratory phase. The heart rate of the patient can also be assessed based on the S1 and S2 RRR, heart tones and murmurs. The patient’s abdomen must also be reviewed for palpitation for tenderness, bowel sounds and check for abdominal bruits. Finally, it is important to check the extremities by conducting a full ROM.
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, pneumonia, interstitial lung disease, 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, 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.
Diagnostic test
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 outcome.
References
Teepe, Jolien, Broekhuizen, Berna Dl, Ieven, Margareta, Loens, Katherine, Huygen, Kris, Kretzschmar, MEE, de Melker, Hester, ... GRACE consortium. (2015). Prevalence, diagnosis, and disease course of pertussis in adults with acute cough: a prospective, observational study in primary care.
Strunk, R. C., Colvin, R., Bacharier, L. B., Fuhlbrigge, A., Forno, E., Arbelaez, A. M., Tantisira, K. G., ... Zeiger, R. (September 01, 2015). Airway Obstruction Worsens in Young Adults with Asthma Who Become Obese. The Journal of Allergy and Clinical Immunology: in Practice, 3, 5, 765.
Gilotra, N. A., Shpigel, A., Okwuosa, I. S., Tamrat, R., Flowers, D., & Russell, S. D. (January 01, 2017). Patients Commonly Believe Their Heart Failure Hospitalizations Are Preventable and Identify Worsening Heart Failure, Nonadherence, and a Knowledge Gap as Reasons for Admission. Journal of Cardiac Failure, 23, 3, 252-256
McComb, B. L., Ravenel, J. G., Steiner, R. M., Chung, J. H., Ackman, J. B., Carter, B., Colletti, P. M., ... Expert Panel on Thoracic Imaging: (January 01, 2018). ACR Appropriateness Criteria® Chronic Dyspnea-Noncardiovascular Origin. Journal of the American College of Radiology: Jacr, 15, 291.
Aakre, C. A., & Iyer, V. N. (March 01, 2015). 73-Year-Old Man with Dyspnea on Exertion. Mayo Clinic Proceedings, 90, 3, 404-407.
Poole, P., Chong, J., & Cates, C. J. (July 29, 2015). Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, 7.)
Virchow, J. C. (January 01, 2016). Diagnostic challenges of adult asthma. Current Opinion in Pulmonary Medicine, 22, 1, 38-45.
Ferry-Rooney, R. (January 01, 2013). Asthma in Primary Care: A Case-based Review of Pharmacotherapy. Nursing Clinics of North America, 48, 1, 25-34.
Kochhar, S. (November 01, 2013). Carrying out asthma reviews in primary care. Nurse Prescribing, 11, 11, 538-541.
Burns, D. (January 01, 2013). Managing acute asthma in primary care. Nursing Times, 109, 42, 17-8. [Show Less]
