Patient Initials _____MRS. X. 65 year old Caucasian female
Subjective Data: she claims she is having severe wheezing, shortness of breath and coughing at least once daily. She states that she took Albuterol once today before visiting the doctor.
Chief Compliant: She can barely get her words out without taking breaks to catch her breath.
History of Present Illness:
Mrs.X had frequent asthma attacks for the past 2 months. On average >4 times/week. She had serious MVA 10 weeks ago. She experienced post traumatic seizure 2 weeks after the accident. When she started anticonvulsant phenytoin therapy – no more seizure activity.
- Patient had periodic asthma attacks since her 20s.
- 3 years ago was diagnosed with mild congestive heart failure;
- she is on sodium restrictive diet and hydrochlorothiazide;
- Last year she was placed on enalapril due to worsening CHF, but symptoms were well controlled last year.
- NO past surgical history.
Significant Family History: Her father died age 59 of kidney failure secondary to HTN; her mother died age 62 of CHF.
Social History: patient is nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Review of Symptoms:
Severe wheezing, shortness of breath and coughing at least once daily suggest that she has respiratory problems.
I give the patient 3 priority diagnoses with ICD-10 codes, placed in order of priority.
- Asthma. (ICD-10-CM Diagnosis Code J45) . The patient already had asthma in her 20s. Asthma is chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe. Other symptoms include wheezing, coughing, tightness in the chest, shortness of breath, and rapid breathing-exactly what she experiences. Such asthma attack may be brought on by pet hair, dust, smoke, pollen, mold, exercise, cold air, or stress.
- Chronic obstructive pulmonary disease (COPD) (ICD-10-CM Diagnosis Code J44.9) is a long-term lung disease. It’s comprised of two diseases: emphysema and chronic bronchitis. It is a chronic and progressive lung disorder characterized by the loss of elasticity of the bronchial tree and the air sacs, as well as, destruction of the air sacs wall, thickening of the bronchial wall, and mucous accumulation in the bronchial tree. The major symptoms include shortness of breath, wheezing, productive cough, and chest tightness, exactly what the patient experienced.
- Bronchial adenoma. (ICD-10-CM Diagnosis Code D38.1). Bronchial adenomas are cancers of the respiratory tract causing a cough, fever, or shortness of breath. The patient’s age and history of respiratory diseases puts her in the risk group for bronchial adenomas.
Plan of Care:
- Asthma. (ICD-10-CM Diagnosis Code J45) . The patient should develop asthma control plan that includes three major zones (GREEN, YELLOW and RED). The patient should be able to identify her zones and know in what zones she is at present. This will help her to deal with asthma more efficiently.
GREEN (doing well). In this zone the patient is doing well, performing all her activities. She takes prescribed medicines and continues enjoying her life. This is the zone in which the patient is the most comfortable and does not need any input from the doctor.
YELLOW (caution). In this zone, she has breathing problems, and cannot perform all activities. She may start with taking some medicines (e.g. Albuterol) and wait for 20 minutes. If no improvement then go to RED zone. If feeling better, she should take Albuterol as scheduled (e.g. every 4-6 hours) for the next 24 to 48 hours. If symptoms continue—she should call doctor.
RED (medical alert). In this zone emergency treatment is likely since breathing is hard and the patient cannot do usual activities. She may be recommended to take more Albuterol (e.g. 4-8 puffs) and wait 15 minutes. If not better or worse, then go to hospital or call 911. If better, she should continue Albuterol every 4-6 hours and call doctors to be seen today or get doctor’s advice.
The patient should follow this protocol and avoid the triggers for asthma, such as furs, pollen or any substances that in her case correlated with her asthma attack.
- Chronic obstructive pulmonary disease (COPD) (ICD-10-CM Diagnosis Code J44.9). The patient needs additional tests to determine COPD. If she has COPD (unlikely) she should follow COPD treatment protocols. For instance she may need oxygen treatment, treatment for muscles and weakness, and, if necessary, a surgery. Medicines may include taking bronchodilators, inhaled steroids, or newly approved roflumilast (Daliresp), a phosphodiesterase-4 inhibitor.
- Bronchial adenoma. (ICD-10-CM Diagnosis Code D38.1).
To diagnose bronchial adenoma, the patient should get the following tests: X-ray, MRI, or biopsy. If she has bronchial adenoma, she should follow the treatment protocols. The treatment will depend on type and stage of cancer, age and health and may include: surgery, radiation, chemotherapy, immunotherapy, or targeted therapy.
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby.
Terry Mahan Buttaro; JoAnn Trybulski; Patricia Polgar Bailey; Joanne Sandberg-Cook, Primary Care, Elsevier – Health Sciences Division