Patient Initials JD.
Subjective Data
Chief Compliant: JD states that “she is having severe wheezing, shortness of breath, and coughing at least once daily.”
History of Present Illness: The patient has been experiencing frequent asthma attacks for the past two months; she takes theophylline and albuterol to manage this condition. A severe motor vehicle accident occurred ten months ago, and JD was hospitalized to receive care. Two weeks after the accident, a post-traumatic seizure was developed, and JD started using anticonvulsant phenytoin that eliminated seizure activity.
PMB/Medical/Surgical History: The client follows a sodium-restrictive diet and takes hydrochlorothiazide enalapril to treat congestive heart failure that was diagnosed three years ago. JD has had a history of periodic asthma attacks for most of her life, since her early 20s. The patient does not have any past surgical history, and no known drug allergies were mentioned.
Significant Family History: The patient’s father died of kidney failure that developed secondary to hypertension when he was 59 years old, while her mother died of congestive heart failure at the age of 62.
Social History: JD neither smokes nor uses alcohol, but she has sufficient caffeine intake because she consumers four cups of coffee and four diet colas daily.
Review of Symptoms: Positive for shortness of wheezing, shortness of breath, coughing, and exercise intolerance. Denies any integumentary, head, eyes, ear, nose, and throat, gastrointestinal, genitourinary, musculoskeletal, neurological, endocrine, hematologic, and psychologic problems.
Objective Data
Vital Signs: BP 171/94; HR 122; PR 31; T 96.7 F; Wt. 145; Ht 5ˈ 3ˈˈ; BMI 25.7 (overweight).
Physical Assessment Findings:
- HEENT: no problems are identified.
- Lymph Nodes: normal.
- Carotids: no inflammation.
- Lungs: bilateral expiratory wheezes.
- Heart: regular rate and rhythm.
- Abdomen: soft, non-tender, no masses.
- Genital/Pelvic: unremarkable.
- Rectum: guaiac test negative.
- Extremities/Pulses: one ankle edema was identified on the right foot without bruising, regular pulses.
- Neurologic: A&O X3, cranial nerves intact.
- Laboratory and Diagnostic Test Results:
- Na – 134: hyponatremia because the value is lower than 135 mEq/L.
- K – 4.9: normal.
- Cl – 100: normal.
- BUN – 21: normal considering the patient’s age.
- Cr – 1.2: elevated (can be a sign of kidney disease).
- Glu – 110: increased (can be a sign of prediabetes).
- ALT – 24: normal.
- AST – 27: normal.
- Total Chol – 190: normal.
- CBC – WNL: normal.
- Theophylline – 6.2: insufficient level.
- Phenytoin – 17: sufficient amount.
- Chest Xray – Blunting of the right and left costophrenic angles: can indicate lung disease.
- Peak Flow – 75/min; after albuterol – 102/min: significantly reduced.
- FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%: low values meaning that abnormalities are present.
Assessment: Three priority diagnoses (with ICD-10 codes) can be offered to the client, and they are as follows:
- J45.1 Nonallergic asthma.
- E11 Type 2 diabetes mellitus.
- I10 Essential (primary) hypertension.
Plan of Care: The given section will present diagnostic and therapeutic management as well as the required education and counseling for each diagnosis.
Numerous factors allow for concluding that JD has nonallergic asthma. Her chief complaint, including abnormalities in the lungs and peak flow test, demonstrates that the patient has some respiratory issues. However, additional diagnostic measures are necessary to determine whether the stipulated diagnosis is appropriate for the patient. Durrington et al. (2018) define that the presence and amount of eosinophils in sputum and blood can help diagnose the condition. Simultaneously, the researchers indicate that the presence of these biomarkers is higher at 4 a.m., meaning that it can be suitable to run laboratory tests at this time of the day (Durrington et al., 2018). An appropriate treatment approach might be to rely on anti-inflammatory reliever therapy, including budesonide or formoterol, because this approach shows increased effectiveness compared to standard treatment involving short-acting beta-agonists (Rapi et al., 2020). This information demonstrates that scientific evidence should guide diagnostic and therapeutic management.
In addition to that, education and counseling are significant in addressing the patient’s condition. It is possible to find many resources that provide this information, but the best strategy is to consult reputable organizations. For example, one can access the website of the Centers for Disease Control and Prevention (2021) to find general information about the diagnosis, when it is necessary to see a doctor, and others. This resource is included in the plan because it offers expert opinions on the topic, and individuals can rely on this data to make the right decisions about their health.
Type 2 diabetes mellitus is the second potential diagnosis, and it is present because JD is overweight and has an elevated level of glucose. Now, it is possible to use a 75 g oral glucose tolerance test or glycated hemoglobin (HbA1c) to diagnose the condition (Forouhi & Wareham, 2018). Once identified, diabetes can be managed with the help of a comprehensive treatment plan. According to the World Health Organization (2021), a suitable management strategy relies on diet, physical activity, and different blood glucose level lowering medications. A significant role in diabetes treatment is associated with appropriate education and counseling. The included resource by the World Health Organization (2021) is suitable for this purpose. In particular, it provides individuals with reliable data about this condition, its screening methods, and how to protect themselves.
Finally, hypertension is the third potential diagnosis, and it is mentioned because JD has significantly elevated blood pressure. According to Nerenberg et al. (2018), regular follow-up assessment plays a crucial role in diagnosing the condition. In particular, such a diagnosis is made when a daytime mean of a person’s blood pressure equals or is higher than 135/85 (Nerenberg et al., 2018). As for available treatment, antihypertensive therapy represents its basis, but stress management, reduced alcohol consumption, weight control, and physical exercise are additional interventions that can lead to better health outcomes (Nerenberg et al., 2018). As with the previous diagnoses, it is reasonable to indicate a helpful resource that people can access to find valuable information about how the condition should be managed and what counseling they should receive. In this case, the Centers for Disease Control and Prevention (2020) offer an article that can demonstrate how individuals can protect themselves from hypertension. It is a reputable organization that offers high-quality data, meaning that people should not hesitate to consult it when they have any doubts regarding their health.
References
Centers for Disease Control and Prevention. (2020). Prevent high blood pressure. Web.
Centers for Disease Control and Prevention. (2021). Learn how to control asthma. Web.
Durrington, H. J., Gioan-Tavernier, G. O., Maidstone, R. J., Krakowiak, K., Loudon, A. S., Blaikley, J. F.,… & Ray, D. W. (2018). Time of day affects eosinophil biomarkers in asthma: Implications for diagnosis and treatment. American Journal of Respiratory and Critical Care Medicine, 198(12), 1578-1581.
Forouhi, N. G., & Wareham, N. J. (2019). Epidemiology of diabetes. Medicine, 47(1), 22-27.
Nerenberg, K. A., Zarnke, K. B., Leung, A. A., Dasgupta, K., Butalia, S., McBrien, K.,… & Canada, H. (2018). Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Canadian Journal of Cardiology, 34(5), 506-525.
Rapi, A., Blasi, F., Canonica, G. W., Morandi, L., Richeldi, L., & Rossi, A. (2020). Treatment strategies for asthma: Reshaping the concept of asthma management. Allergy, Asthma, & Clinical Immunology, 16(75). Web.
World Health Organization. (2021). Diabetes. Web.