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Respiratory Clinical Case, Assessment and Care Plan

Patient Initials

G. M. D.

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Subjective Data

The patient is a 65-year-old female of Caucasian origin who was discharged from the hospital almost three months ago after she had been injured in a car crash. The patient complains of frequent cough, shortness of breath, and wheezing. She also claims that it is even difficult for her to speak properly without making pauses to take a breath, not to mention the physical activity. Today, she states that she has taken albuterol to alleviate the symptoms.

Chief Complaint

It is difficult for me to breathe even when I talk. I am also coughing and wheezing.

History of Present Illness

The patient has a history of asthma attacks since her early 20s, but they occurred very rarely. However, nearly three months ago, she was involved in a motor vehicle accident. Two weeks after the accident, she had a post-traumatic seizure and was placed on anticonvulsant phenytoin which terminated the seizure activity. Then, approximately two months ago, she began to experience frequent asthma attacks. On average, they were more than four times a week. Since that time, she has been suffering from these attacks.

PMH/Medical/Surgical History

Three years ago, the patient was diagnosed with mild congestive heart failure and was placed on hydrochlorothiazide and sodium restrictive diet. Due to worsening CHF a year ago, she was placed on enalapril, which considerably alleviated the symptoms. The patient has no surgical history. The prescribed medications include Theophylline SR Capsules 300 mg PO BID, Albuterol inhaler, PRN, Phenytoin SR capsules 300 mg PO QHS, HTCZ 50 mg PO BID, and Enalapril 5 mg PO BID. Regarding allergies, the patient has NKDA.

Significant Family History

The patient’s father died of kidney failure and had HTN at the age of 59. Her mother died of CHF at the age of 62.

Social History

The patient does not smoke and consumes no alcohol. In terms of caffeine, on average, she drinks four cups of coffee and four diet colas every day.

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Review of Symptoms

The patient is positive for wheezing, coughing, shortness of breath, and exercise intolerance. She denies seizures, swelling in the extremities, and a headache.

General: abnormalities in cardiovascular and respiratory systems; Integumentary: normal; Head: normal; Eyes: normal; ENT: normal; Cardiovascular: hypertension; Respiratory: wheezing, coughing, shortness of breath; Gastrointestinal: normal; Genitourinary: normal; Musculoskeletal: slight lateral curvature; Neurological: normal; Endocrine: normal; Hematologic: normal; Psychological: mild restlessness.

Objective Data

Vital Signs

BP 169/92, HR 120, RR 29, T 96.9 F, Wt 142, Ht 5’2”

VS after treatment with Albuterol – BP 132/77, HR 78, RR 17

Physical Assessment Findings

Gen: Pale, well-developed female is appearing anxious. HEENT: PERRLA, no lesions in the oral cavity, no signs of inflammation in TM, no nystagmus observed. Cardio: Regular rate and normal S1 and S2 rhythm. Chest: Bilateral expiratory wheezes. Abd: non-tender, soft, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on left, normal pulses, no bruising. NEURO: cranial nerves intact, A&O X3.

Laboratory and Diagnostic Test Results

Na – 132

K – 5.0

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Cl – 102

BUN – 20

Cr – 1.4

Glu – 111

ALT – 22

AST – 26

Total Chol – 191


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Theophylline – 6.1

Phenytoin – 19

Chest Xray – Blunting of the left and right costophrenic angles

Peak Flow – 74/min; after albuterol – 101/min

FEV1 – 1.7 L; FVC 3.1 L, FEV1/FVC 62%


Pleural effusion (ICD-10 diagnosis code is J91.8)

According to the results of the analyses, the most probable condition that can cause such symptoms is pleural effusion. The chest x-ray showed the blunting of the left and right costophrenic angles, which indicate this particular disease. Moreover, pleural effusion can be associated with congestive heart failure and in rare cases, with asthma (Wilcox et al., 2014). Additionally, it can be easily caused by a car accident.

Chronic bronchitis (ICD-10 diagnosis code is J41.0)

Considering the patient’s current state, chronic bronchitis is also possible in this case. Its main symptoms include coughing, shortness of breath, wheezing, chest discomfort, fatigue, and, sometimes, slight fever (Kim & Criner, 2013).

Emphysema (ICD-10 diagnosis code is J43.9)

Emphysema is also possible in this case, as it has similar symptoms, namely, shortness of breath, wheezing, and coughing. Besides, it can cause chest pain (Deslee et al., 2014).

Plan of Care

  1. Pleural effusion can be treated with the help of several methods. Small pleural effusions can be treated by themselves. The most common treatment of larger effusions is thoracentesis, whereby these effusions are pumped out. Very large effusions may require surgical intervention to break the adhesions. The use of medications in the case of pleural effusion is mostly auxiliary. However, antibiotics should be used when this condition is caused by an infection (Wilcox et al., 2014).
  2. In general, chronic bronchitis is incurable, except for lung transportation. Therefore, the treatment of this disease is focused on relieving the symptoms, decelerating the progression of the disease, and preventing complications. For this purpose, such medications as guaifenesin and albuterol are used to reduce cough, and various mucolytics to improve breathing (Kim & Criner, 2013).
  3. Emphysema is also a chronic, incurable disease, except for lung transportation. To treat it, the same strategy as with chronic bronchitis is used. Steroids, mucolytics, and in the case of other respiratory comorbidities, antibiotics are most effective. Additionally, oxygen therapy, protein therapy, and other methods of pulmonary rehabilitation can significantly alleviate the symptoms of the disease (Deslee et al., 2014).


Deslee, G., Klooster, K., Hetzel, M., Stanzel, F., Kessler, R., Marquette, C. H.,… & Hetzel, J. (2014). Lung volume reduction coil treatment for patients with severe emphysema: A European multicentre trial. Thorax, 69(11), 980-986.

Kim, V., & Criner, G. J. (2013). Chronic bronchitis and chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 187(3), 228-237.

Wilcox, M. E., Chong, C. A., Stanbrook, M. B., Tricco, A. C., Wong, C., & Straus, S. E. (2014). Does this patient have an exudative pleural effusion?: The rational clinical examination systematic review. JAMA, 311(23), 2422-2431.

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