Clinical Record on Patient With Coughing - Paper Example

The patient has problems with coughing. The patient has a cough and has been wheezing for a couple of days. The coughing has gotten worse. The patient coughs with productive sputum; there is no swelling, and there is a mild SOB.

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The patient has in the past been diagnosed with asthma, bloating, diverticulosis, sigmoid (mild), diabetes mellitus, external hemorrhoid, fibroids, hypercholesterolemia, hypertension, knee gives out, osteoporosis, rheumatoid arthritis, and vitamin D deficiency.

Past surgical procedures that have been done on the patient include upper endoscopy, HX colonoscopy, HX hysterectomy and PB colonoscopy. Upper endoscopy was done on the patient in August 2004, HX colonoscopy was done on the patient in August 2004, and PB colonoscopy was done on the patient in May 2010.

The patients family members have in the past suffered from pulmonary problems, diabetes, heart problems, hypertension and musculoskeletal problems. The patient does not smoke tobacco, he has never smoked tobacco, and he does not live with a smoker.

Currently, the patient drinks wine, liquor (mixed drink) but she does not drink beer. The patient rarely drinks; the last time he drunk alcohol was in July 2012. The patient does not use any recreational drug. The patient is married and is neither a perpetrator nor a victim of domestic violence. The patient is heterosexual, and she does not engage in any form of high-risk behaviors. The patient is retired, and the last full-time job he did was in customer service. The patient has a college degree, he is not disabled, and she has not engaged in any form of military service. The patient lives with his family and can perform activities of daily living.

Primary diagnosis reveals that the patient has asthma. Secondary diagnoses reveal that the patient has Type 2 diabetes mellitus with hyperglycemia. Secondary diagnosis also reveals that the patient suffers from rheumatoid arthritis that involves an unspecified site and an unspecified rheumatoid factor.

SECTION 2- PATHOPHYSIOLOGY

Physical Exam

Constitutional: She is an oriented person with regard to place and time. She appears well- developed and well nourished. The patient exhibits non toxic appearances and she is not distressful.

HENT:

Head: Normocephalic and atraumatic

Eyes: Conjunctivae and EOM are normal. Pupils are equal, round and reactive to light.

Neck: Normal range of motion. Neck is supple. No JVD present.

Cardiovascular: Regular rhythm and normal heart sounds. Tachycardia is present.

Pulmonary/chest: Effort normal. No respiratory distress. She has wheezes. She has rhonchi.

Abdominal: Soft. Bowel sounds are normal. She exhibits no mass. There is no tenderness.

Musculoskeletal: Normal range of motion. She exhibits no edema or tenderness.

Neurological: She is alert and oriented to person, place and time. GCS eye subscore s 4. GCS verbal subscore is 5. GCS motor subscore is 6.

Skin: Skin is warm and dry. No rashes are noted on the skin.

Psychiatric: she has a normal mood and affect. Her behavior is normal.

SECTION 3- MEDICATION REGIMEN

Scheduled medications

MEDICATION NAME DRUG

CLASS ACTION / PHARMACOKINETICS DOSING

RANGES COMMON

SIDE EFFECTS NURSING PRECAUTIONS & MONITORING RATIONALE FOR USE SPECIFIC TO PATIENT

Albuterol Bronchodilator Inhalation 2.5mg/3ml Back pain, headache, dizziness, nausea It should not be used in large or small amounts Ipratropium Anticholinergic Inhalation 0.5 mg inhalation Stomach upset, nausea, dizziness A doctor should prescribe the medication Prednisone GlucocorticoidsOral 60 mg Sleep problems, increase in appetite, nausea, headache The drug should be taken with food. Magnesium sulfate Laxative Intravenous 2g/50 ml Allergic reactions, dizziness, muscle paralysis Use the drug as directed by the doctor. The drug should be out of childrens reach

PRN medications (administered within the last 48 hours):

MEDICATION NAME DRUG

CLASS ACTION / PHARMACOKINETICS DOSING

RANGES COMMON

SIDE EFFECTS NURSING PRECAUTIONS & MONITORING RATIONALE FOR USE SPECIFIC TO PATIENT

Lansoprazole Proton-pump inhibitor Oral 30 mg Nausea, stomach pain, headache, diarrhea. If taking sucralfate, one should avoid taking Lansoprazole Vitamin E capsule Tocopherols Oral 400 units It might increase chances of developing a stroke. If one has a heart disease or diabetes, he should not take doses of 400 IU/day or above. Acetaminophen Miscellaneous analgesics Oral 500 mg Nausea, dark urine, jaundice One should miss a dose and neither should he overdose Aspirin Salicylates Oral 81 mg Upset stomach, mild headache, drowsiness One should take the medicine if he or she smells a strong odor of vinegar in the bottle

SECTION 4- LAB & DIAGNOSTIC TEST DATA

Last Vitals

Blood pressure: 109/56 (03/16/17 1438).

Pulse: 108 (03/16/17 1602)

Temperature: 99.1 F (37.3 C) (03/16/17 1140)

Respiration: 20 (03/16/17 1602)

Height: 160 cm (03/16/17 1140)

Weight: 72.1 kg (03/16/17 1438)

SpO2: 94% (03/16/17 1438)

SECTION 5- ASSESSMENT

My assessment of this case is that the patient suffering from asthma should be accorded appropriate healthcare management. Failure for the patient to be accorded appropriate healthcare management is likely to have a considerable burden on patients. Asthma management will play a major role in ensuring that even though the patient has asthma, she may be able to stay active and have a peaceful sleep. The patient should be educated on how she can live empowered despite having asthma. Studies have revealed that self- management among asthma patients is likely to improve outcomes in the patients. Self- management should include actions that ensure flare-ups associated with asthma are reduced. Patients with asthma are likely to benefit more from programs that improve patient outcomes.

Assessment of asthma control is very important because it enables making up of decisions on how to control asthma and ensure that the patient leads a life that frees from suffering and pain. Assessment of asthma will play a major role in ensuring that therapy is adjusted in such a manner to ensure that the patient responds to medication in a right manner.

The patient has to ensure that she sticks with his asthma action plan. The action plan will involve a patient knowing how to prevent symptoms of asthma as well knowing how to act in case of an asthma attack.

Making a correct diagnosis of asthma is the first step towards controlling the disease. Diagnosis of asthma is positive after it is established that there is obstruction of air flow in the lungs. A detailed medical history has to be ascertained from the patient before the diagnosis of asthma can take place. Physical examination has to be made with a focus on the upper respiratory tract. Results of spirometry should also be established. The severity of asthma should also be ascertained in a patient. Ascertaining severity of asthma will play a major role in making a decision on how to go about with asthma management.