Asthma

History of Present Illness

D.R. is a 27 yo man, who presents to the nurse practitioner at the Family Care Clinic complaining of increasing SOB, wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage-all of which began four days ago. Three days ago, he began monitoring his peak flow rates several times a day. His peak flow rates have ranged from 200 to 240 L/minute (baseline, 340 L/minute) and often have been at the lower limit of that range in the morning. Three days ago, he also began to self-treat with frequent albuterol nebulizer therapy. He reports that usually his albuterol inhaler provides him with relief from his asthma symptoms, but this is no longer sufficient treatment for this asthmatic episode.

Asthma

Past Medical History

• Born prematurely at 6 months' gestation secondary to maternal intrauterine infection; weight at birth was 2 lbs, 0 ounces; lowest weight following delivery was 1 lb, 9 ounces; spent 2½ months in neonatal ICU and was discharged from hospital 2 weeks before mother's original due date
• Diagnosed with asthma at age 18 months
• Moderate persistent asthma since age 19
• Has been hospitalized 3 times (with 2 intubations) in the past 3 years for acute bronchospastic episodes and has reported to the emergency room twice in the past 12 months
• Perennial allergic rhinitis X 15 years

Asthma

Family History

• Both parents living
• Mother 51 yo with H/O cervical cancer and partial hysterectomy
• Father 50 yo with H/O perennial allergic rhinitis and allergies to pets
• No siblings
• Paternal grandmother, step-grandfather and maternal grandmother are chain smokers but
• do not smoke around the patient

Social History

• No alcohol or tobacco use
• Married with two biological children and one stepson
• College graduate with degree in business, currently employed as a business development consultant with private firm
• There are no pets in the home at this time

Asthma

Review of Systems

• Reports feeling unwell overall, "4/10"
• Denies H/A and sinus facial pain
• Eyes have been watery
• Denies decreased hearing, ear pain, or tinnitus
• Throat has been mildly sore
• (+) SOB and productive cough with clear, yellow phlegm for 2 days
• Denies diarrhea, N/V, increased frequency of urination, nocturia, dysuria, penile sores or discharge, dizziness, syncope, confusion, myalgias, and depression

Asthma

Medications

• Fluticasone 100 mcg po BID (oral inhalation)
• Triamcinolone MDI 2 inhalations QID
• Albuterol MDI 2 inhalations every 4-6 hours PRN

Allergies

• Grass, ragweed, and cats → sneezing and wheezing

Asthma

Physical Examination and Laboratory Tests

General Appearance

• Agitated, WDWN white man with moderate degree of respiratory distress
• Loud wheezing with cough
• Eyes red and watery
• Prefers sitting to lying down
• SOB with talking
• Speaks only in short phrases as a result of breathlessness

Asthma

Physical Examination and Laboratory Tests

Vital Signs

See Patient Case Table 12.1

Patient Case Table 12.1 Vital Signs
BP                             150/80	RR               24	HT      6'1"
P                               115	T                 100.2°F	WT     212 lbs
Pulsus paradoxus      20	Pulse ox      92% (room air)

Skin

• Flushed and diaphoretic
• No rashes or bruises

ASTHMA

HEENT

• EOMI
• PERRLA
• Fundi benign, no hemorrhages or exudates
• Conjunctiva erythematous and watery
• Nasal cavity erythematous and edematous with clear, yellow nasal discharge
• Hearing intact bilaterally
• TMs visualized without bulging or perforations
• Auditory canals without inflammation or obstruction
• Pharynx red with post-nasal drainage
• Uvula mid-line
• Good dentition
• Gingiva appear healthy

ASTHMA

Neck/lymph Nodes

• Neck supple
• Trachea mid-line
• No palpable nodes or JVD noted
• Thyroid without masses, diffuse enlargement, or tenderness

Chest/Lungs

• Chest expansion somewhat limited
• Accessory muscle use prominent
• Diffuse wheezes bilaterally on expiration and, occasionally, on inspiration
• Bilaterally decreased breath sounds with tight air movement

ASTHMA

Heart

• Tachycardia with regular rhythm
• No murmurs, rubs, or gallops
• Sl and S2 WNL

Abdomen

• Soft, NT/ND
• No bruits or masses
• Bowel sounds present and WNL

ASTHMA

Genitalia/Rectum

• Deferred

Musculoskeletal/Extremities

• ROM intact in all extremities
• Muscle strength 5/5 throughout with no atrophy
• Pulses 2 + bilaterally in all extremities
• Extremities clammy but good capillary refill at 2 seconds with no CCE or lesions

ASTHMA

Neurological

• Alert and oriented to place, person, and time
• Thought content: appropriate
• Thought process: appropriate
• Memory: good
• Fund of knowledge: good
• Calculation: good
• Abstraction: intact
• Speech: appropriate in both volume and rate
• CNs II-Xll: intact
• Fine touch: intact
• Temperature sensation: intact
• Vibratory sensation: intact
• Pain sensation: intact
• Reflexes 2+ in biceps, Achilles, quadriceps, and triceps bilaterally
• No focal defects observed

ASTHMA

Laboratory Blood Test Results

See Patient Case Table 12.2

Patient Case Table 12.2 Laboratory Blood Test Results
Na                              139 meq/L	Hb                              13.6 g/dL	Monos                              6%
K                                 4.4 meq/L	Hct                              41%	Eos                                   3%
Cl                               105 meq/L	Plt                               292 X 103/mm3	Basos                               1%
HCO3                         26 meq/L	WBC                           8.9 X 103/mm3	Ca                                     8.8 mg/dL
BUN                           15 mg/dL	Segs                           51%	Mg                                    2.5 mg/dL
Cr                                0.9 mg/dL	Bands                         2%	Phos                                 4.1 mg/dL
Glu, (non-fasting)       104 mg/dL	Lymphs                       37%

Note: Normal values, please refer to Laboratory Values posted on Canvas

ASTHMA

Peak Flow

175 L/min

Arterial Blood Gases

• pH 7.55
• PaCO₂ 30 mm Hg
• PaO₂ 65 mm Hg

Note: Normal values, please refer to Laboratory Values posted on Canvas

Chest X-Ray

Hyperinflated lungs with no infiltrates that suggest inflammation/pneumonia

ASTHMA

Clinical Course

The patient is admitted for treatment with oxygen, inhaled bronchodilators, and oral prednisone (60 mg/day initially, followed by a slow taper to discontinuation over 10 days). However, the patient becomes increasingly dyspneic and more agitated despite treatment. Heart rate increases to 125 bpm, pulsus paradoxus increases to 30 mm Hg, respiratory rate increases to 35/min, and breathing becomes more labored. Wheezing becomes loud throughout both inspiratory and expiratory phases of the respiratory cycle. Signs of early cyanosis become evident. The extremities become cold and clammy and the patient no longer is alert and oriented. Repeat ABG are: pH 7.35, PaO₂ = 45 mm Hg, and PaCO₂ = 42 mm Hg (40% oxygen by mask).

ASTHMA

Medical Abbreviations

bpm                    beat per minute	CCE                  clubbing, cyanosis, edema
CN                     cranial nerve	H/A                    headache
H/O                    history of	ICU                    intensive care unit
MDI                   Metered-dose inhaler	N/V                    nausea/vomiting
Pulse ox            pulse oximetry	SOB                  shortness of breath
WDWN              well-developed, well-nourished

ASTHMA

Clinical Values for Case Study Problem-Solving

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations

Khan Academy

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Khan Academy