Subjective
The patient states that she has been experiencing shortness of breath while at work. The patient cannot identify the onset of the symptoms but states that she has had them for a few months. The shortness of breath experienced by the patient is usually mild, which allows her to continue working. During one episode, her symptoms were more severe, causing her to visit an urgent care clinic. The patient denies new allergies, heartburn, and sputum and rates her overall health as good.
The patient lives with husband and 3 children and works at a bakery. She also reports living a relatively healthy lifestyle. The patient does not smoke or take drugs but drinks alcohol socially. She sleeps between 6 and 7 hours each night and exercises regularly. The patient’s family history suggests the late onset of heart disease and cancer in the family, but satisfactory overall health.
The patient is also up-to-date on all vaccinations and had two past surgeries: tonsillectomy and cholecystectomy. Despite reporting good health, she admits having a history of allergic reactions, particularly to strawberries and erythromycin, to which she had previously developed a severe gastrointestinal upset. The patient has also had eczema as a child and has seasonal allergies, causing her to take allergy shots and Zyrtek to avoid symptoms.
Objective
The patient is alert with normal vital signs and body composition. BMI is 20.1, which indicates normal weight. The general presentation is positive, no significant issues detected during the assessment. The patient’s eyes, ears, nose, and throat are clear, with no current symptoms of allergy. Skin clear, no rash detected. Slight wheezing was noted during lung examination, which does not clear with a forced cough. Cardiovascular and abdominal examinations indicated no issues.
Assessment
The patient’s EMR report from 2016 contained a CXR from the time she had bronchitis. The CXR report was positive with no abnormalities noted. Pulmonary functional testing was ordered to establish the presence of an obstructive or restrictive process. The testing reveals a decreased FVC during the pre-bronchodilator challenge, which improved significantly after bronchodilator.
Plan
The primary diagnosis following the results of functional tests is asthma. According to the American Academy of Allergy, Asthma & Immunology (AAAAI, 2014), the ICD-10 code of the diagnosis is J45.30 mild persistent asthma (uncomplicated). The diagnosis was established based on the results of functional pulmonary tests as well as the examination of the patient and subjective data reported. The ICD code for asthma includes predominantly allergic asthma, which seems to be the case with the client. Given that the shortness of breath only occurs at work, exposure to allergens in the workplace is possible. The patient will be referred to an allergologist to perform allergy tests and determine whether asthma was triggered by an allergic reaction. Until the source of symptoms is clarified, the patient should consider taking her allergy medication as prescribed by allergologist to relieve the symptoms.
As noted by the AAAAI (2018), there is no treatment that can completely cure asthma, which is why patient education is essential. It is important to ensure that the patient understands the importance of taking controller medications, as well as the mechanism of asthma. Since the symptoms seem to be allergy-driven and only occur at work, it is also crucial to educate the patients on common workplace allergens in the food industry and on possible ways of avoiding them. Ideally, if the diagnosis is confirmed, it would be best for the patient to leave her job to avoid continuous exposure to allergens. However, this might damage the patient’s living situation by reducing household income, which is why the patient will most likely try to avoid quitting her job. Thus, educating the patient on possible alternatives could help her avoid worsening of the symptoms and development of moderate or severe asthma.
In addition, it would be important to educate the patient on various controller medications available for her condition. As explained by AAAAI (2018), controller medications have to be taken daily and include corticosteroid tablets, combination inhalers, and leukotriene modifiers. Furthermore, the patient should be advised on emergency medications that can be taken if the shortness of breath is severe or persistent. Moreover, the patient should also receive information on other factors that might be contributing to her condition. For example, if she lives in a polluted area, she is at a higher risk of developing respiratory complications. As shown in a study by Baldacci et al. (2015), exposure to biological allergens and air pollutants increases the risk of allergic reactions and may thus affect the severity. Ensuring that the patient’s exposure to pollutants and biological allergens is minimized would have a positive effect on her treatment and symptoms.
In terms of physical activity, no additional guidelines are required. The patient reports exercising 5 times a week and does not experience shortness of breath while exercising, which is why it is not necessary to alter the patient’s activity. However, the patient should be advised to report any asthma symptoms during exercise immediately to avoid the progression of the condition. The follow-up visit should be scheduled for a later date (3-4 weeks) so that the patient has enough time to visit allergologist and perform all the necessary tests.
Overall, the patient’s condition is rather mild and can be controlled using simple lifestyle adjustments and medication. The key goal of the appointment is to provide the patient with information about her health and possible ways of minimizing the symptoms. Once further results are obtained from the allergologist, it would be possible to choose the best medication for therapy.
References
The American Academy of Allergy, Asthma & Immunology (AAAAI). (2014). Asthma codes for ICD-10.
The American Academy of Allergy, Asthma & Immunology (AAAAI). (2018). Asthma treatment and management. AAAAI. Web.
Baldacci, S., Maio, S., Cerrai, S., Sarno, G., Baïz, N., Simoni, M., … Viegi, G. (2015). Allergy and asthma: Effects of the exposure to particulate matter and biological allergens. Respiratory Medicine, 109(9), 1089-1104.