It also makes me feel anxious, but no other symptoms that I can think of. ” Exposures: NP: “ Have you had any recent colds or infections? Do you smoke or around second hand smoke? ” Patient: “ l have never been a smoker and I am not around much second hand smoke. I used to be a bartender and was around a lot of smoke then, but that has been a few years. I haven’t had any recent colds or infections. ” Childhood Illnesses: Chicken pox Medical: None Past History surgical: 2000, C-section 2011 b/Gym: Gravid 2/Para 2 VGA delivery 2010, C-section 2011 Psychiatric: None Immunization: Current.
Adapt 2011, Flu shot Cot 2013.
Screening Test: Pap 2013 Personal and Social History Education: Associated degree, general studies. Support system: Husband, 2 children. Denies marital stress. Parents, family, and friends ! Leisure activities: Reading, activities with kids Diet: Reports balanced diet. Weight conscious, tries to eat healthy and limit sweets.
! Sleep: Denies interrupted sleep. Reports 7-8 hours per night. ! COMMA Family- Husband, kids and parents. Recreation- Spending time with husband, kids and friends. Enjoys reading. Social- Gets together with friends monthly for dinner.
Religion- Attends a Christian church weekly.
SONOGRAM Maternal grandmother (70) – living: TN, arthritis Maternal grandfather (65) – deceased: MI, smoker Paternal grandmother (69) – living: Diabetes, obesity Paternal grandfather (72)- living: TN Mother (50) – living: Depression, asthma, seasonal allergies Father (52) Sister (28)- living: Asthma Brother (26) – living: Smoker Complete History and Physical – living: TN General: States feeling healthy other than the respiratory issues. Denies any other complications or concerns. Skin: Denies any abnormal or concerning moles. Denies edema, denies any rashes, itching, or bruising.
HEN: Head: Denies headaches and dizziness, other than when SOB. Denies any recent head trauma or syncope. Eyes: Wears glasses, no contacts. Denies any visual disturbances, such eyes diploma, blurred vision, or recent changes in visual acuity. Denies any excessive tears or discharge. Last eye exam Novo 2013.
Ears: Denies tinnitus, ear pain, vertigo, discharge, excessive cerement, or hearing loss or difficulty hearing. Nose: Denies rhinoceros, congestion, and apostasies. Denies nasal tenderness. Denies history of nasal trauma. Questions having allergies due to SOB.
Throat: Denies dysphasia, sore throat, swelling, or hoarseness.
Neck: Denies any swollen nodes, pain, stiffness, decreased ROOM. ! Breast: Performs USB monthly. Denies lumps, pain, discharge, asymmetry, or growth Respiratory: Complains of SOB, wheezing. Difficulty performing activities due to the SOB. Denies cough, sputum production, or recent infection.
Denies hex of pneumonia. Questions if she has asthma or allergies. Denies history of smoking or exposure to second hand smoke. Cardiovascular: Denies history of cardiac anomalies, palpitations, chest pain, and tachycardia. Denies peripheral edema. Denies history or murmurs.
Denies CUP with the SOB, Just a generalized chest tightening.
Reports, “ l don’t feel it in my heart, other than a little anxious when it happens, maybe my heart speeding up”. Gastrointestinal: Denies nausea, vomiting, diarrhea. Denies bloody stools. Reports daily BMW with no constipation. Denies reflux, excessive gas, and abdominal pain.
Peripheral Vascular Disease: Denies leg pain or swelling, minor spider veins in lower extremities bilaterally. Denies numbness or tingling, disconsolation, or redness. Urinary: Denies pain or difficulty urinating. C/O stress incontinence with coughing/ sneezing; reports performing Keel exercises when she remembers.
Denies hex of IT’S. Genital: Menarche age 14, LIMP last week.
Reports regular periods. DID for birth control, placed 2011. Hex one vaginal birth, one c-section. Had last pelvic exam November 2013. Denies vaginal discharge, pain, itching. Denies history of vaginal infections or Stir’s.
Musculoskeletal: Denies muscle pain or stiffness. Reports full ROOM. Denies Joint pain or swelling. Psychiatric: Denies any hex of depression, mood changes. Feels some anxiety with the SOB peels odes. Neurological: Denies history of seizures, syncope, headaches, aphasia, memory loss.
Mild dizziness with SOB episodes.
Hemolytic: Denies any abnormal bleeding or bruising. Denies hex of anemia. Denies hex of menorahs. Denies hex of blood transfusion. No history of cancer.
Endocrine: Denies heat or cold intolerance. Had thyroid levels checked previously tit no abnormalities reported to patient. Denies history of diabetes or signs of polyphonic or Polynesia. Denies tremors. Physical Exam General: Height 5’8″, Weight of boss. IBM21 . Well groom appearance, no s/s of distress. Gait normal. Cooperative with questioning. Appears no respiratory distress at this time.
Alone for exam. No body odors.
Vital Signs: BP 117/62, HRS 102, R 24, T 98. 1, paten O. Esp. on RA.
! Skin: Intact with no lesions present. Warm, dry. No masses, rashes, or disconsolation. No bruising present. HEN: Head: Morphophonemic, 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 photos, 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 pains. No excessive cerement or drainage notes. Tympanis membrane intact.
No redness noted. Positive whisper test. Nose: Negative for drainage or bleeding. No lesions or masses noted. Septum midlines without deviation.
NO sinus tenderness with palpation. Throat: Oral mucosa pink, moist, thou lesions or patchier noted. Gag reflex present. Good oral hygiene noted, no analysts s Neck: Trachea midlines. No lumps, tenderness, or masses palpated.
Neck supple, no stiffness or decreased ROOM noted. Thyroid non-tender, no goiters or nodules present. No JIVED noted.
Thorax and Lungs: AP/transverse ratio 1: 2. Breath expansion equal bilaterally. Lungs calculated, wheezing present on expiration near end of cycle.
No signs of occasions, no tachyon, mild labored breathing present. Lymph Nodes: No enlarged or tender lymph nodes palpated. Cardiovascular System: Apical pulse strong and regular, PM located at 5th interconnect space at MAC. SSL and SO present with no extra heart sounds or murmurs noted. Regular rhythm with tachycardia present. No JIVED present.
No carotid bruit present. Peripheral Vascular: Strong radial and dorsal piped pulses present, +3.
Cap refill 2 seconds in all extremities. No signs of clubbing or occasions at nail beds. No edema present.
Spider veins to posterior legs bilaterally. No tenderness upon palpation. No redness or swelling in lower extremities. Nervous System: Alert and oriented x 3. Clear speech, no slurring of words noted.
Cranial nerves I to XII intact. Dart’s +2 at aphrodisiac’s and patella. Differential Diagnosis 2. 3. 4.
5. 6. 8. Asthma Allergies (environmental) Bronchitis Pneumonia Pulmonary Embolism Heart Failure URI Anemia Diagnostic Tests CB with differential. Chest X-Ray. Speedometer (measurement of NC and FEE !
Diagnostic Impression CB: Within normal limits.
No elevation of sinkhole counts ! Chest X-Ray: Hyperinflation noted with no evidence of consolidation noted. ! Speedometer: FIVE: NC: 75 % predicted FIVE : Treated with Alabaster inhaler, then repeated speedometer testing FIVE : Improved to 83%, a 13% increase Diagnosis: Asthma List of why some diagnosis were eliminated Asthma was the ruled in diagnoses following the results of the history and labs. The speedometer testing snowed a reach compared to ten I-PVC, wanly Is consistent with asthma. Improvement in long function testing noted after alabaster administration. .
Bronchitis: Negative chest x-ray, history not consistent with this DXL. Febrile. 2. Pneumonia: Negative chest x-ray, CB WON. No elevated white count.
3. Pulmonary Embolism: History not consistent with DXL. Negative on chest x-ray. 4. Heart Failure: Negative history, no edema, swelling, liver enlargement, or cardiac murmurs present.
5. URI: Negative for fever, elevated WBI count, productive cough. 6. Anemia: CB WON. No evidence of bleeding.
Plan of care-follow up Send patient home with short-acting bronchiolar, such as alabaster, to use as needed for SOB.
Patient will be started on an inhaled low-dose corticosteroid. Will follow up with patient in 1-2 weeks to monitor asthma and treatment effectiveness. After that, if treatment is effective will follow up in 1 month for re-veal. Then follow every 6 months unless exacerbations occur or as needed.
Patient will be sent home with prescription for PEE meter. Will be educated on use, to use during symptom free period or after utilizing maximum therapy (alabaster). To assure twice daily and bring record to follow up visits. Medications busybodies (Pulmonary) peg/inn, take 2 inhalations BID.
Alabaster peg/inn, take 1-2 inhalations as needed every 4-6 hours Peek Flow Meter Education Record PEE twice daily, and how to use meter.
To bring log to next visit in 1-2 weeks. Red zone signifies a medical emergency, take alabaster inhaler ASAP and seek emergency treatment. Yellow signifies worsening asthma, and alabaster inhaler should be used ASAP, and follow up with provider if consistently in yellow zone or using rescue inhaler (alabaster) 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 PEE showing in red zone, seek medical treatment, and utilize alabaster inhaler. Keep alabaster inhaler with you at all times. Get alabaster inhaler refilled before running out of the one you have.
References Archangel, V. P. & Peterson, A. M. (2013). Parasympathetic’s for advanced