-
- QUESTION
Clinical Diagnostics
Case Study #2
DATE:
NAME:
SUBJECTIVE
Patient Initials
M.B.
Patient Age
16 years
Patient Gender
Female
Chief Complaint (CC)
[in quotation marks]
“nighttime non- productive cough 2-3 times per month for the past 3 months associated with shortness of breath”
History of Present Illness (HPI)
Allergies
NKDA
Past Medical History (PMH)
Patient has a history of recurrent upper respiratory infections and had bronchitis 2 years ago. No hospitalization or emergency department visits. Current medications include OTC diphenhydramine (Benadryl) for her intermittent runny nose and an occasional puff from her friend’s albuterol inhaler during soccer games.
Family History
Household members include M.B., her mother, father and older sister (age 18) who live in a house in a more rural community just outside of Saint Louis, MO. The father had a history of seasonal hay fever as a child, later called allergic rhinitis and topical dermatitis. Both parents are indoor and outdoor smokers. The mother reports her husband has had some difficulties with episodic cough and shortness of breath but has not seen a physician.
Personal/Social History
Lives at home with mother, father and sister. They live in a more rural than suburban area, a lot of farms nearby. The family has a pet dog and an indoor cat. The patient will start 11th grade at the local high school in the fall. She is a good student academically, has no school absences. Patients states she does not smoke cigarettes, use any drugs or inhaled substances, or drink alcohol.
Developmental/Functional History
Menarche began at age 14. Periods are regular, with normal bleeding and last approx. 6 days total. She has met developmental milestones and followed a 50th percentile growth curve.
Review of Systems (ROS)
No recent weight gain or loss. Denies anxiety or depressive symptoms. Positive for numerous episodes of sneezing, itchy eyes, and clear nasal discharge. Denies ears or throat symptoms. Positive for shortness of breath and non -productive cough 2-3 nights a week that resolve spontaneously. SOB and cough also occur with exercise such as playing soccer. Denies chest pain or palpitations. Denies vomiting, diarrhea, dysuria. Denies joint pain.
OBJECTIVE
Vital Signs (VS)
T = 37° C (98.6° F), HR = 82, RR = 16, BP = 118/76; Weight = 54 kg; Height = 5'4"
Physical Exam (PE)
You ask the mother to leave the examination room. This allows you to to ask the patient confidentially if she has been smoking or is around friends who smoke. The patient states that neither she nor any of her friends smoke cignarettes or any inhaled substances, such as marijuana.
General Appearance: Well appearing. Alert, oriented x 3. CN II-XII intact.
SHEENT: Skin is P/W/D, no rashes. Head is normocephalic. PERRLA. Optic disks visualized distinctly. No conjunctival injection, no drainage, no discharge. Nares reveal boggy, red turbinates with moderate congestion, but no sinus tenderness or flaring. Bilat.TMs are mobile and without erythema or air/fluid levels. Posterior pharynx is unremarkable. Neck with normal ROM. No cervical lymphadenopathy. Thyroid palpated and is without abnormality.
Cor/Chest: Chest wall is without visible foreign bodies, tattooing, bruising, deformity. Chest inspection does not show accessory muscle use or intercostal, suprasternal, or supraclavicular retractions. The antero-posterior diameter does not seem to be increased. Pulmonary auscultation reveals inspiratory and expiratory wheezing scattered throughout both lung fiends. Her peak expiratory flow rate (PEFR) reading is 340 liters per minute (L/min). RRR without murmur.
Abd/GU: No visible foreign bodies, tattooing, bruising or abnormalities. Positive bowel sounds. Soft, nondistended, nontender, no palpable masses. No hepatosplenomegaly. Female genitalia deferred. LMP 3 weeks ago.
Extremities: Cool and moist. MAEW. Palpable radial and pedal pulses. No visible abnormalities. No clubbing of fingers, nailbed pink with good cap refill.
Note: You explain to M.B. and her mother that her predicted normal peak flow should be 427 which is the predicted normal for her age and build.
Diagnostics: Office spirometry done showing an obstructive defect:
FVC - 5 to 18 years: ≥ 80%
FEV1 /FVC - 5 to 18 years: < 85% Obstructive defect
An in -office bronchodilator was administered with FEV1/FVC ratio returned to normal.
ASSESSMENT
Differential Diagnoses?
[10 points]
List them in order of most likely to least likely
The DDx list is the most important list for these case study exercises. It is from this list that you will decide what diagnostics (if any) are needed. This list guides your decision-making and provides the “blueprint” for how you are approaching the case. Make sure you pay attention to ALL parts of the H&P and do not make a random list of what could be. Especially in infants and children, even minor ddx need to be listed. Finally, list your DDx in descending order (as best you can) of what your suspicion is for what the final diagnosis might be.
Treatments/Education?
[5 points]
This section should utilize elements learned from the clinical practice guideline and any additional elements that pertain to the case.
PLAN
Diagnostics?
[5 points]
The diagnostics to be considered or ordered should be a reflection of the clinical practice guidelines and any additional diagnostics that pertain to the case.
DIAGNOSIS
Final or Working Diagnoses [1point]
(TBD in our zoom class session)
ICD-10 code(s) [ 1point]
(TBD in our zoom class session)
CPT code(s) [1 point]
(TBD in our zoom class session)
Prescription(s) [2 points]
(TBD in our zoom class session)
Questions (All answers should have a source cited)
- Briefly discuss the definition and pathophysiology of asthma in the population. [2.5 points]
- Outline the steps involved in making an asthma diagnosis at the initial visit and include a short discussion of what is done during each step. Use the case study patient exam and history in your discussion. [10 points]
- M.B has several environmental triggers for her asthma and allergies. List 3 of these triggers, discuss how they can contribute to asthma exacerbation and discuss how to educate M.B.’s mom and M.B. on these triggers and how to decrease her exposure to them. [15 points]
Reference List [2.5 points]
| Subject | Nursing | Pages | 3 | Style | APA |
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Answer
Clinical Diagnostic: Case Study 2
Table 1: Case Study 2
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DATE: |
NAME: |
|
SUBJECTIVE |
|
|
Patient Initials |
M.B. |
|
Patient Age |
16 years |
|
Patient Gender |
Female |
|
Chief Complaint (CC) [in quotation marks] |
“nighttime non-productive cough 2-3 times per month for the past 3 months associated with shortness of breath” |
|
History of Present Illness (HPI) |
M.B. is Caucasian female who comes to your office with her mother for evaluation of her cough. Mom states that M.B. has a nocturnal nonproductive cough 2 to 3 times per month for at least the past 3 months associated with increasing episodes of shortness of breath that usually resolve spontaneously. However, during soccer games, M.B. has recurrent episodes of cough and wheezing that are only relieved when she uses a friend’s albuterol inhaler. |
|
Allergies |
NKDA |
|
Past Medical History (PMH) |
Patient has a history of recurrent upper respiratory infections and had bronchitis 2 years ago. No hospitalization or emergency department visits. Current medications include OTC diphenhydramine (Benadryl) for her intermittent runny nose and an occasional puff from her friend’s albuterol inhaler during soccer games. |
|
Family History |
Household members include M.B., her mother, father and older sister (age 18) who live in a house in a more rural community just outside of Saint Louis, MO. The father had a history of seasonal hay fever as a child, later called allergic rhinitis and topical dermatitis. Both parents are indoor and outdoor smokers. The mother reports her husband has had some difficulties with episodic cough and shortness of breath but has not seen a physician. |
|
Personal/Social History |
Lives at home with mother, father and sister. They live in a more rural than suburban area, a lot of farms nearby. The family has a pet dog and an indoor cat. The patient will start 11th grade at the local high school in the fall. She is a good student academically, has no school absences. Patients states she does not smoke cigarettes, use any drugs or inhaled substances, or drink alcohol. |
|
Developmental/Functional History |
Menarche began at age 14. Periods are regular, with normal bleeding and last approx. 6 days total. She has met developmental milestones and followed a 50th percentile growth curve. |
|
Review of Systems (ROS) |
No recent weight gain or loss. Denies anxiety or depressive symptoms. Positive for numerous episodes of sneezing, itchy eyes, and clear nasal discharge. Denies ears or throat symptoms. Positive for shortness of breath and non -productive cough 2-3 nights a week that resolve spontaneously. SOB and cough also occur with exercise such as playing soccer. Denies chest pain or palpitations. Denies vomiting, diarrhea, dysuria. Denies joint pain. |
|
OBJECTIVE |
|
|
Vital Signs (VS) |
T = 37° C (98.6° F), HR = 82, RR = 16, BP = 118/76; Weight = 54 kg; Height = 5'4" |
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ASSESSMENT |
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Treatments/Education? [5 points] This section should utilize elements learned from the clinical practice guideline and any additional elements that pertain to the case.
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Treatment
Patient Education Educate the patient and her mom on the association between risk factors such as overcrowding, smoking, exposure to secondary smoke, animal dander/fur, poor ventilation, biomas fuel use and exposure to fumes/dust with asthma, allergic rhinitis, and COPD (Idani et al., 2019; Sinha, Singla, & Chowdhury, 2015). Adverse effects of each prescribed medication should be included in patient and family education. |
|
Prescription(s) [2 points] |
(TBD in our zoom class session) Albuterol inhaler to be used when there is need (Durbin, 2020).
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Questions (All answers should have a source cited)
- Briefly discuss the definition and pathophysiology of asthma in the population. [2.5 points]
My Response
Asthma is a chronic inflammatory disease that affects the airways. The disease is associated with hyper-responsiveness of the airways to common allergens, irritants, or specific triggers such as allergens, viruses, and physical exercise. It is associated with recurring symptoms such as breathlessness, wheezing, chest tightness, and/or coughing (Quirt et al., 2018).
- Outline the steps involved in making an asthma diagnosis at the initial visit and include a short discussion of what is done during each step. Use the case study patient exam and history in your discussion. [10 points]
My Response
At the initial visit steps that taken in diagnosing asthma are outlined below:
- Taking of medical history
- It includes seeking information about classic symptoms of asthma such as chest tightness, wheezing, breathlessness, and cough (with or without sputum) (Quirt et al., 2018). In the case, history taking indicated that the M.D. was experiencing wheezing and breathlessness during physical exercises.
- Symptom patterns: recurrence or episodic, worsen/occur early in the morning, and worsen/occur with exposure to allergens (Quirt et al., 2018). In the case study, the patient’s cough was recurrent and state of breathlessness tends to worsen at night.
- Respond to asthma therapy (Quirt et al., 2018). M.D. response well to albuterol therapy.
- Physical examination
- Examination of the patient for wheezing on auscultation (Quirt et al., 2018). Similarly, in the provided case study pulmonary auscultation indicated inspiratory and expiratory wheezing, which is scattered throughout both lung fiends.
- Examination of the patient for skin and upper respiratory tract for signs of other atopic conditions (Quirt et al., 2018). M.D.’s skin was found to be pink, warm and dry with no rashes.
- Objective measures to confirm variable expiratory –airflow limitation (spirometry is preferred)
- Documentation of airflow limitation. If FEV1 IS low then FEV1/FVC should be determined on whether it has been reduced. Normal FEV1/FVC in children is >0.90 and >0.75 to 0.80 in adults (Quirt et al., 2018). Similarly, spirometry was performed for the patient in the case study and determined as low.
- Documentation of the variability of the lung function (Quirt et al., 2018). In the office, an administered bronchodilator had immediate effect in adjusting FEV1/FVC ratio to normal.
- Allergy testing: Performance to skin tests so as to identify allergy status and potential triggers (Quirt et al., 2018). Under planned tests.
- M.B has several environmental triggers for her asthma and allergies. List 3 of these triggers, discuss how they can contribute to asthma exacerbation and discuss how to educate M.B.’s mom and M.B. on these triggers and how to decrease her exposure to them. [15 points]
My Response
Identified environmental triggers for M.B.’s asthma include exposure to secondary cigarette smoke, exercise, and animal dander. These are known triggers that can cause allergy, asthma, and may lead to exacerbation of asthma (Quirt et al., 2018). M.B.’s mom and father are both smokers. In fact they usually smoke inside the house, which exposes her to secondary cigarette smoke. History taking revealed that M.B. experienced state of breathlessness, wheezing, and cough after engaging in physical exercises. These symptoms were resolved only after she used her friend’s albuterol inhaler. From the provided case study, exercise was presented as a trigger for exacerbation of her condition. Lastly, but not the least, the family lives with an indoor cat and a pet dog. It has established that animal fur and dander are triggers for asthmatic crisis or for development of the condition (Quirt et al., 2018).
M.B. and her mom should be educated on the role that cigarette smoke, exercise, and animal dander/fur play a role in development and exacerbation of asthma. Education will be delivered through face-to-face sessions and by letting them to view appropriate education videos on YouTube. To reduce exposure to these triggers M.B.’s parents should stop smoking; or at least not to smoke in a way that exposes her to secondary smoke, advising her not to engage in strenuous exercises, and by doing away with the pet dog and the indoor cat.
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DIAGNOSIS |
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Final or Working Diagnoses [1point] |
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ICD-10 code(s) [ 1point] |
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CPT code(s) [1 point] |
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References
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Centers for Disease Control and Prevention. (May 16, 2019). Asthma. https://www.cdc.gov/asthma/data-analysis-guidance/ICD-9-CM-ICD-10-CM.htm Centers for Disease Control and Prevention. (May 25, 2017). Prevention and treatment. https://www.cdc.gov/niosh/topics/asthma/treatment.html Das, S., Dunbar, S., & Tang, Y-W. (2018). Laboratory diagnosis of respiratory tract infections in children – the state of the art. Front Microbiol., 9, 2478. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200861/ Durbin, K. (Feb 03, 2020). Albuterol inhalation. https://www.drugs.com/albuterol.html Hossenbaccus, L., Linton, S., Garvey, S., & Ellis, A. (2020). Towards definitive management of allergic rhinitis: best use of new and established therapies. Allergy, Asthma & Clinical Immunology, 16, Article number: 39. https://aacijournal.biomedcentral.com/articles/10.1186/s13223-020-00436-y ICD-10-CM Coding Guide. (2020). J30.9 – Allergic rhinitis, unspecified. https://www.unboundmedicine.com/icd/view/ICD-10-CM/906409/all/J30_9___Allergic_rhinitis__unspecified#:~:text=J30.,unspecified%20%7C%20ICD%2D10%2DCM Idani, E., Raji, H., Madadizadeh, F., Cheraghian, B., Shoshtari, H., & Dastoorpoor, M. (2019). Prevalence of asthma and other allergic conditions in adults in Khuzestan, Southwest Iran, 2018. BMC Public Health, 19, Article number: 303. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-6491-0 Pham, H. T., Nguyen, P. T. T., Tran, S. T., & Bhung, T. T. B. (2020). Clinical and pathogenic characteristics of lower respiratory tract infection treated at the Vietnam National Children’s Hospital. Canadian Journal of Infectious Diseases and Medical Microbiology, 2020, Article ID 7931950, 1-6. https://doi.org/10.1155/2020/7931950 Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy Asthma Clin Immunol., 14(Suppl 2), 50. https://dx.doi.org/10.1186%2Fs13223-018-0279-0 Saglani, S., & Menzie-Gow, A. (2019). Approaches to asthma diagnosis in children and adults. Front Pediatr., 7, 148. https://dx.doi.org/10.3389%2Ffped.2019.00148 Sinha, B., Singla, R., & Chowdhury, R. (2015). Allergic rhinitis: A neglected disease – a community based assessment among adults in Delhi. Journal of Postgraduate Medicine, 61(3), 169-175. http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2015;volume=61;issue=3;spage=169;epage=175;aulast=Sinha SuperCoder. (2019). ICD-10-CM Code. https://www.supercoder.com/icd-10-codes/J30.9 Widysanto, A., & Mathew, G. (2020). Chronic bronchitis. [Updated 2020 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482437/ World Health Organization. (2013). Pocket book of hospital care for children: guidelines for the management of common childhood illnesses (2nd ed.). Geneva: World Health Organization. https://www.ncbi.nlm.nih.gov/books/NBK154448/
Appendix
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