... Has there been any shortness of breath? We provide high-quality papers covering a wide range of services. It is classified as a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs (Cazzola 1997). This is a significant risk factor for respiratory illness. Tommy should be able to manage his asthma attacks with his inhalers. Some football players, and ex-football players, still smoke (or live with smokers). Address both medications and include a discussion regarding how they work together to help manage Tommy’s asthma. Uncontrolled asthma not only takes a toll on the patients’ body, but on their daily lives and finances as well. A female patient presents with respiratory distress. There was a family history of colon cancer. If the symptom is shortness of breath, the severity can be bluntly assessed by assessing if the patient is able to speak in full sentences without having to take a breath. Discuss the relationship between the pathophysiology of asthma to specific findings in Tommy’s clinical manifestations. If, for example, you are describing the course of a truly otherwise healthy 40-year-old who presents with 3 days of cough, fever, and shortness of breath as might occur with pneumonia, you can focus on that time frame alone. Tommy’s oxygen saturation is at 90% during resting, which is considered low, nasal flaring, wheezing, and retractions. Lastly, based upon your analysis, is a Step 2 level of care appropriate for his management? A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. He works as a truck driver, and the symptoms began four days … Shortness of breath. Long whole travel, malignancy, recent surgery, pregnancy, procoagulant stage, Recurrent lower respiratory tract infractions (e.g. Beclomethasone (Qvar) is an inhaled corticoid steroid medication used to aid in those with asthma. Below is a Student Sample ORDER YOUR PAPER NOW, Asthma affects over 26 million people in the United States alone (Morris 2016). HISTORY OF PRESENT ILLNESS: This 52-year-old male was admitted as a direct admission from the clinic for worsening shortness of breath, hypoxia, tachypnea, fever, and severe anemia where he was diagnosed prior … Shortly thereafter the cough became productive of yellowish/green sputum and he According to the Center for Disease Control, uncontrolled asthma is associated with decreased quality of life and increased health care system use. Porth, C. M. (2015). History of Present Illness- Tommy Respiratory Case Study, 15-year-old Tommy reports to urgent care with shortness of breath. 2. Family history Athletes with asthma (or exercise-induced bronchospasm) often have a family history of asthma. The pain is not associated with shortness of breath, nausea, or diaphoresis. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. When the body is suffering from asthma, the airways inflame and constrict, allowing little to no air to flow through them. We must determine if these new medications will better control his asthma. A history of asthma during childhood, for example, may be discovered this way and keep the physician from prescribing certain heart medicines that may provoke an asthmatic attack. Pharmacological Basis of Prescribed Medications. He has occasional interference with daily activities -just like today when he was unable to participate in basketball practice because of his breathing difficulty. Confirm that the chief complaint is shortness of breath. History of Present Illness (HPI). Most cases of shortness of breath are due to heart or lung conditions. Dr. Loiuse Gooch, ward doctor), dentity: confirm you’re speaking to the correct patient (name and date of birth), ermission: confirm the reason for seeing the patient (“I’m going to ask you some questions about your cough, is that OK?”), ositioning: patient sitting in chair approximately a metre away from you. CHIEF COMPLAINT: Shortness of breath. Below is a Student Sample ORDER YOUR PAPER NOW Tommy is currently reporting shortness of breath and chest tightness. Our services include term papers, research papers, book reviews, homework assignments, dissertations, assignments, business papers, and thesis papers. This is a Student Sample ORDER YOUR PAPER NOW. CC: The patient is a 62 year old male with a history of mild COPD who complains of cough, shortness of breath, fatigue, and fever progressively worsening for the past week. patient present to you. Free medical revision on history taking skills for medical student exams, finals, OSCEs and MRCP PACES, Perfect revision for medical student exams, finals, OSCEs and MRCP PACES. Her discomfort was accompanied by shortness of breath, but associated symptoms no sweating, nausea, or vomiting. Some form of HPI is required for each level of care for every type of E/M encounter. We noted previously that physical activity has triggered his asthma attacks. Each section of the paper requires professional references published within the past five years. These symptoms are considered the pathophysiological signs of asthma indicating that his body is not getting an adequate amount of oxygen causing him to have trouble breathing. Albuterol is a beta-adrenergic agonist that works on the lungs (Cazzola 1997). Constitutional symptoms: fever, weight loss (quantify how much), night sweats? Pull in specific data and compare it to the parameters required in order to classify as having mild persistent asthma. Over the past 24 hours she reports worsening shortness of breath. Albuterol inhalation is used to treat or prevent bronchospasm in people with reversible obstructive airway disease. History of Present Illness (Please include a detailed description of the present illness including past medical and surgical history-paint a picture) What brought your client to this facility? Nearly every student wishes to succeed in his or her future career, and it is inseparably linked to your competence in research paper writing. Consider only the abnormal signs and symptoms that could be a direct result of the asthma. History of the Present Illness: Mr.--- is a previously healthy 56-year-old gentleman who presents with a four day history of shortness of breath, hemoptysis, and right-sided chest pain. The first thing of importance is determining what triggers Tommy’s asthma attacks. Determine if this is a new problem or an exacerbation of a chronic condition. The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath. It can sometimes be difficult to pin down the exact symptom(s) making the patient present. Discuss any potential interactions and precautions that should take place because of those risks (i.e., should a medication be discontinued or should there be close monitoring of certain things, etc…). Symptoms are … Frequency of exacerbations, admissions (as for asthma): home oxygen (number of hours and rate of flow), any home nebulizers. Copyright 2013-2019 Oxford Medical Education Ltd. ntroduce yourself: give your name and your job (e.g. Her past medical history was only significant for asthma and a 30 pack-year smoking history. Of course, your paper needs to be in but with this template, all you must do is removed our stuff and replace it with yours and get your citations right! Other problems may cause shortness of breath on exertion as well. History and Physical Medical Transcription Sample Report #3. Shortness of breath caused by anxiety or panic may be accompanied by rapid heartbeat, sweating, and chest pain. Asthma can be managed with the right collaboration between patient and doctor (Braido 2013). There are two durations to consider: the total illness and, if symptoms are episodic, the duration of a typical episode. History of the presenting complaint (HPC) • Cardiac symptoms: palpitations, ankle swelling, PND, orthopnoea? He required oral glucocorticoids for an exacerbation about 4 months ago. Shortness of breath (dyspnea) is usually caused by lung or heart disorders. *** Even though there are therapies and medications out there to help with this, people still suffer from their symptoms, which can take a toll on their life. Congestive heart failure also leads to shortness of breath 3. Flaring nostrils are usually seen in infants and children, which is an important symptom for communicating respiratory distress (Bottrell 2016). Asks about symptoms, smoking, and personal and family history of respiratory disease. If the patient has not come to you directly, find out why they presented to someone else first. Ask what precipitated the problem and what, if anything, makes the Tommy will continue his albuterol treatments that were prescribed to him previously. DATE OF ADMISSION: MM/DD/YYYY. any hobbies you can no longer perform due to your breathing. The history dictates whether or not the patient needs further work-up or testing, and the urgency with which they should be … We would need to monitor Tommy’s heart rate and blood pressure since Tommy is taking albuterol. History of Present Illness (Please include a detailed description of the present illness including past medical and surgical history-paint a picture) What brought your client to this facility? : Mrs. D is 65 year old Caucasian female presents in the ED for shortness of breath and difficulty taking deep breaths. PMH is significant for Parkinson's, COPD, chronic bronchitis, on home O2, HTN, DM, GERD, gastroparesis. He reports using his inhaler about 3-4 times a week for the past month. Shortness of breath occurs as a result of the interaction of many physical and even psychological factors. Congruence with Clinical Practice Guidelines. Philadelphia, PA. Wolters Kluwer Health|Lippincott Williams & Wilkins. Glucocorticoids are hormones in the body that prevent inflammation and immune responses when taken into the body (Burgt 2000). He just used his inhaler while sitting in the waiting room. Includes checking fingers, legs, and feet for swelling. Case Presentation. Since Tommy has a pulse over 100 at this time, we would want to make sure the albuterol doesn’t cause him to be even more tachycardic. 6. To put this into perspective, if a patient comes in for shortness of breath, it is essential to include that the patient has a history of COPD, asthma, or pneumonia. Doctors first ask questions about the person's symptoms and medical history. Everyone in the party apparently … number of stairs, distance on the flat), Cardiac medications, including: diuretics: ACE inhibitors, antianginals, Coal, dust, asbestos, fumes, moulds (e.g. female who presented to the ED c/o SOB, weakness, decreased appetite x 2 days. Your heart and lungs are involved in transporting oxygen to your tissues and removing carbon dioxide, and problems with either of these processes affect your breathing. For example, should a medication be discontinued or should there be close monitoring of certain things? hay), Pets (especially birds), farming, any animals involved in hobbies, Myasthenia Gravis (MG) – Neurological Examination, Questions about DVT (Deep Vein Thrombosis), Endotracheal tube (ETT) insertion (intubation), Supraglottic airway (e.g. Albuterol in adjunct with Qvar should help Tommy’s lungs to relax and expand. Module 6 Case Analysis Discussion Points 1. Jackie is a 48-year old female who presented to the Emergency Department with shortness of breath that was present at rest and which severely limited activity. Based upon the data provided and parameters included in the guidelines for the diagnosis and management of astha, do you agree with this diagnosis? Emily Campbell is a 48-year-old female who has presented to A&E with a week of chest pain with some shortness of breath. History of Present Illness Please answer the following questions Chief Complaint What is the main reason for your child’s visit today? Do his manifestations align with those parameters? Reliability of clubbing in the cardiovascular exam, If they are uncertain about the start of the shortness of breath, a good question is: “When were you last well?”. Include abnormal diagnostic tests as applicable. Some HPIs are rather straight forward. If this same patient mentions that he broke his ankle 5 years ago, there is no need to mention that in the HPI because it has absolutely no relevance to shortness of breath. What are the abnormalities of the heart sounds? Tommy was admitted to a step 2 level of care floor with monitoring for his breathing. 4. Full medical history but ask specifically about: Frequency of attacks, admission to hospitals, admissions to ITU, need for non invasive ventilation (NIV). The last time he got the pain, he took an aspirin, which he thinks helped. 3. Cough: productive or dry, colour of sputum, change in colour of sputum? She states that she has a history of COPD and attempted to use her home inhalers with minimal relief. number in the last year, any antibiotics taken). Doctors then do a physical examination. These symptoms include wheezing, feeling short of breath and coughing after different exposures and environmental changes (Morris 2016). laryngeal mask airway [LMA], i-Gel), Click here for the differential diagnosis of shortness of breath, Click here for how to take history in chest pain, Lung Function Tests (Spirometry And Peak Flow) – Respiratory Medicine. Certain Drugs and Medications. Remember that this may be a symptom of conditions affec-ting systems other than the chest (for example, hypovolaemia attributable to bleeding). For example,, the statements “patient reports shortness of breath” and “the patient reports shortness of breath, chest pain, nausea, vomiting, & vision disturbances” both generate credit for just one HPI element - Associated Signs and Symptoms. Provide references to support your response. Essentials of pathophysiology: Concepts of altered health states (4th ed.). Hemoptysis: how much (teaspoonful, cupful), how frequently? It is also used to prevent exercise-induced bronchospasm (Cazzola 1997). Chest pain: pleuritic, cardiac-sounding, nausea, sweating? She recently visited the emergency department 3 weeks ago and was sent home on azithromycin and a … Tommy complains of having shortness of breath with exertion and nocturnal asthma. e.g. Shortness of breath (SOB), also known as dyspnea (BrE: dyspnoea) is a feeling of not being able to breathe well enough. Work through the case to … Quantify how far the patient can walk before stopping due to shortness of breath (e.g. Asthma can be triggered by different external and internal factors. Exam includes checking weight and height, and listening to heart and lungs. Shortness of breath that comes on suddenly (called acute) has a limited number of causes, including: Ensure you are sitting at the same level as them and ideally not behind a desk, Relation to exertion, time of day (morning dips in asthma). Provide references to support your response. Analyze ALL of Tommy’s prescribed and over-the-counter (OTC) medications for potential drug-drug interactions. In chronic asthma cases, there is increased bronchial hyper-responsiveness in the airways as a result to a long-term trigger (Morris 2016). Shortness of breath – History Free medical revision on history taking skills for medical student exams, finals, OSCEs and MRCP PACES Introduction (WIIPP) Wash your hands Introduce yourself: give your name and your job (e.g. Explains risk factors. Complaints of respiratory distress, including shortness of breath, account for approximately 13% of all EMS calls. He reports cold-like symptoms for the past 3-4 days, and Tommy’s mother has been giving him over-the-counter (OTC) medications to help treat his symptoms. Tommy is using his albuterol metered-dose inhaler 3-4 times a week for the past month. Chief Complaint: Shortness of breath History of present illness: Betty Ann Bernell is a 95 y.o. History of Present Illness. There is a strong genetic component. He was diagnosed with asthma a year and a half ago and was prescribed an albuterol metered-dose inhaler (MDI) every 4- 6 hours as needed. Patient was on BiPAP at time of examination, therefore majority of HPI obtained from daughter at bedside. It is associated with more trips to the doctor’s office and more medications, which can equal out to more money. Analyze ALL of Tommy’s prescribed and OTC medications for potential drug-drug interactions. According to the National Institutes of Health, people with well controlled asthma should have few, if any, asthma symptoms throughout the day (NIH 2011). For example, a patient with chest pain, shortness of breath, leg pain, and recently traveled might tell a provider to look for a blood clot that has caused a pulmonary embolism ***The quiz for day 1 will be taken at the beginning of day 2, hold off on taking any quizzes until instructed to do so by the Instructor during the course. All of these symptoms indicate that Tommy is having difficulty with breathing. Examples of lung problems causing shortness of breath include chronic obstructive pulmonary disease, a disease of lung tissue often associated with smoking 1. [3] Discuss Tommy’s prescribed drug therapy (beclomethasone and albuterol) in relation to drug purpose, mechanism of action, metabolism and excretion, dosage and adverse effects. When discussing the diagnostic tests, relate Tommy’s values to normal values and discuss their significance. When present, the pain is not worsened by movement or breathing. Wheezing occurs when the small airways of the lungs become narrow or constricted (TNACA 2012). Specifically, he has been taking Claritin-D daily for the past 3 days and Delsym for his cough as needed. Tommy was prescribe a low-dose beclomethasone (Qvar) and to continue his albuterol inhaler every 4-6 hours. Provide references to support your response. The History of Present Illness (HPI) is defined by location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms. This is a Student Sample ORDER YOUR PAPER NOW, Pathophysiology and Clinical Manifestations. Provide references to support your response. He just used his inhaler while sitting in the waiting room. Social history This is an important consideration. He reports awakening at night with asthma attacks about 4 times this past month. As a matter of fact, only particular people are gifted with a talent for writing. History of Present Illness (HPI) ... Quote the patient directly as needed, "my teeth itch," for example. Provide references to support your response. Wheezing can be a symptom of asthma where a combination of swelling, mucus and muscles tightening can cause narrowing of the airways (Morris 2016). Internal factors can include respiratory infections or allergic reactions. Triple Bottom Line: Evaluating Performance, Training on Performance Evaluations Scenario, Moral Psychologists and Behavioral Economists, Cut Some Foreign Aid to African Countries. Tommy was diagnosed as having mild persistent asthma and was placed in Step 2 level of asthma care. Asthma can be noted as either acute or chronic. What doctors find during the history and physical examination often suggests a cause and the tests that may need to be done (see table Some Causes and Features of Shortness of Breath). In people with a chronic lung disorder (such as chronic obstructive pulmonary disease) or heart disorder (such as heart failure), the most common cause of dyspnea is a flare-up of the chronic disorder, but these people can also develop a new problem (such as a heart attack) that contributes to or causes dyspnea. HPI: The patient believes the fatigue and dry cough began just over one week ago. Urinary Tract Infections Proteinuria (Protein in Urine) Hydronephrosis Kidney Stones Urinary Frequency Urinary Incontinence Bedwetting Hydrocele Is there any change when the patient lays down or sleeps? : Mrs. D is 65 year old Caucasian female presents in the ED for shortness of breath and difficulty taking deep breaths. Orally inhaled corticoid steroids inhibit this inflammation process allowing air to flow in and the person to breathe easier (Burgt 2000). CHIEF COMPLAINT: Shortness of breath. If we can control Tommy’s asthma then his symptoms will be managed, he will not be restricted from physical activity, and he will be able to sleep through the night without having shortness of breath. History of Present Illness (HPI) Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. Discuss any potential interactions and precautions that should take place because of those risks. Symptoms began approximately 2 days ago with productive cough. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old previously healthy male who went out for a party a night and a half ago. Tommy is suffering from the effects of asthma without relief. Dr. Loiuse Gooch, ward doctor) Identity: confirm you’re speaking to the correct patient (name and date of birth) Permission: […] The pain lasted ... detail than is shown in this example, why you felt the dyspnea is more likely to be from ischemic heart disease, and not Asthma can affect the airways and cause shortness of breath. For follow-up visits, it is acceptable to call the HPI an “Interval History.” This interruption in daily activities is atypical, however, usually occurring no more than once per month. Shortness of breath is a side effect of several medications including beta-blockers, statins, ACE inhibitors, and chemotherapy drugs. HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 67 year old who comes into the hospital after waking up short of breath. What do they tell us? He reports using his inhaler about 3-4 times a week for the past month. The History of Present Illness (HPI) is used to describe the status of the symptoms or clinical problems from time of onset or since the previous encounter with the physician. Past history of ischemic heart disease, cardiac failure or structural heart disease. History of Present Illness (HPI). He denies any recent fever, cough, or infectious symptoms. Some external factors could include the weather, pet dander or pollen. Why or why not? Below is a Student Sample ORDER YOUR PAPER NOW Tommy is currently reporting shortness of breath and chest tightness.
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