Comprehensive Case Analysis of Asthma

Comprehensive Case Analysis

SOAP NOTE

1. 
   SUBJECTIVE INFORMATION
   
   1. 
      Identifying data
      
      : 17y/o Caucasian female
   2. 
      Source
      
      : Patient and Grandmother, reliable historians
   3. 
      CC
      
      : Congestion and Cough
   4. History of Present Illness (HPI): 17-year-old female presents to clinic with c/o cough and nasal congestion. 3 days ago, pt. came home from school with onset of nasal congestion and a dry cough that has progressively worsened and is now accompanied by a sore throat, fever that began yesterday afternoon. Pt states the cough is now productive with tan sputum and yellowish nasal discharge. Patient’s grandmother kept her home from school yesterday and tried treating her symptoms with OTC Zyrtec and Alka-Seltzer cold medicine which had provided some modest relief of congestion and reduced her fever but did not improve her cough. Last night she awoke from sleep with cough, shortness of breath and chest tightness; she woke her grandmother who reports she had audible wheezing. Patient was able to gain respiratory relief after using her albuterol inhaler but woke frequently due to coughing. Patient reports that her cough is worse at night and early morning while her sore throat and congestion seem worse during the day. She reports having slept most of yesterday and still feels tired today. Patient does recall a history of seasonal allergies, and grandmother reports that her pulmonologist had suggested she take Claritin but has not since she was in middle school. Pt reports spending the weekend outside at the lake with her church youth group just prior to onset of symptoms.
   5. Current medications:
      1. ProAir HFA 2 puffs inhaled Q4-6 hours prn for shortness of breath and/or wheezing. (Reports using inhaler 3-4/month on average)
      2. OTC: Zyrtec 10 mg PO daily for the last two days along with Alka Seltzer cold medicine a couple of times a day for two days.
   6. Past Medical History:
      1. Asthma – diagnosed at age 5
      2. Mild scoliosis
      3. Frequent ear infections as a child
   7. 
      Past Surgical history:
      
      Pressure equalization tubes in bilateral ears in 14 and 22 months.
   8. Health Maintenance:
      1. Immunizations: MMR x 2 doses 2002, 3rd IVP dose 2005Tdap 2011, HPV x 3 doses 2007, Meningococcal 2007. Influenza 2018.
   9. Family History:
      1. Allergies (sister)
      2. Asthma (sister)
      3. Hypertension (father)
      4. AMI (paternal grandfather)
      5. Mental Illness-schizophrenia (mother)
      6. Diabetes (paternal grandmother)
   10. 
       Social History:
       
       Lives at her paternal grandmother’s house with her father and younger sister. She is a senior at Monmouth High School where she reports making good grades and is hoping to go to King’s college with two of her best friends next year to work toward becoming an elementary school teacher. She is active in the First Baptist youth group. Reports regular exercise but is not involved in team sports. Reports consuming a healthy low-fat diet most of the time with occasional splurges. Denies current or past sexual activity, illicit drug use, ETOH use, and tobacco use. Denies smoking but is exposed to second hand smoke in the home.
   11. 
       Allergies:
       
       NKDA
   12. Review of Systems (ROS):
       1. GEN: Reports fever, fatigue, and decreased appetite but denies changes in weight.
       2. SKIN: Denies any skin rashes, lesions, ulcerations, or abnormalities.
       3. HEENT: Reports intermittent tension headaches for the last few days along with decreased sense of smell and significant nasal congestion and drainage as detailed in HPI. Denies change in hearing, ear pain or ringing in the ears. Denies watery or itchy eyes or change in vision.  Reports sore throat as detailed above in HPI.
       4. RESP:  Reports cough and SOB and chest tightness as per HPI. Denies hemoptysis, or pain upon inspiration or expiration. Denies night time asthma awakenings other than last night. Denies feeling short of breath or using inhaler since last night.
       5. CV:  Denies chest pain or palpitations. Denies any extremity swelling. Report chest tightness as detailed in HPI.
       6. GI: Denies nausea, vomiting, hematemesis, abdominal pain, change in bowel habits, or heartburn.
       7. GU: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
       8. MUSC: Denies muscle pain or aches, arm or leg weakness, joint swelling or arthritis.
       9. NEURO: Denies syncope, seizures, disorientation, anxiety, inability to concentrate, or difficulty with balance.
       10. OB/GYN: Regular 30-day menses cycle. Pt. denies sexual activity. Denies painful ovulation or cramping. Denies breast tenderness but reports bloating usually just prior to menses.
       11. PSYC: Denies depression, anxiety, or changes in mood.

2. OBJECTIVE INFORMATION
   1. Vital Signs: Temperature: 99.8 (tympanic), Pulse 76, Respirations 24, BP 94/72 Height: 65in. Weight: 123 pounds BMI: 20.5
   2. Physical Exam
      1. General: Well-groomed teenage female, appropriately dressed in no acute distress but appears obviously ill.

2. INTEGUMENTARY: Skin pink, warm and dry without rash or lesion. Mild facial flushing noted. Elastic with good skin turgor; capillary refill less than three seconds.

3. HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Pressure reported upon palpation of frontal maxillary sinuses. Eyes: Sclera white, conjunctiva pink, no icterus, excessive tearing, or exudate; lids non-remarkable and appropriate for race; no edema or lesions noted; PERRLA. Visual acuity and extraocular eye movements intact. Ears: Bilateral canals patent and non-tender, no erythema. No edema, lesion, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Nose: Bilateral nares congested with rhinorrhea; boggy, edematous turbinates, yellow drainage noted. Septum midline. Throat: Posterior oropharynx erythematous, but without tonsillar edema or exudate; uvula midline. Mucous membranes pink, moist, without ulceration. Dentist: sees regularly, last cleaning and checkup Nov. 2017, got braces removed in 2009

4. NECK: supple, non-tender. No cervical lymphadenopathy. No submental, postauricular, or supraclavicular lymphadenopathy noted. No thyroid nodule or thyroidmegaly. Trachea midline.

5. CHEST: Thorax symmetric, non-tender, with symmetric expansion.  Pt. tachypneic but no use of accessory muscles or evidence of retractions. Breath sounds vesicular with diffuse bilateral expiratory wheezes upon auscultation; no crackles or rhonchi noted. Lungs resonant upon percussion without evidence of consolidation. Congested cough with small amount of thin yellow-beige sputum.

6. CV: RRR w/o murmur, rub or gallop. S1 and S2. Extremities warm, dry and well perfused with 2+ palpable bilateral radial and dorsalis pedis pulses.

7. ABDOMEN: flat, soft non-distended and non-tender with no rash, palpable masses or hepatosplenomegaly. Bowel sounds active.

3. Labs – rapid strep test – negative

3. Assessment
   1. Acute Upper Respiratory Tract Infection (ICD 10 – J06.9) –
   2. Acute Asthma Exacerbation (ICD 10 – J45.901)
4. Plan
   1. Pharm
      1. Albuterol 5mg NEB x 1 dose now
      2. ProAir HFA 2 puffs Q 4-6 hours prn for shortness of breath; Disp 1 inhaler, 3 refills
      3. Medrol Dose Pack; taper dose as directed by 4mg/day over 6 days beginning with 24 mg the first day. Disp. 1 dose pack, No refills.
      4. Flonase 50mcg/spray; 2 sprays in each nostril daily. Disp: 1, Refills
      5. OTC: Zyrtec 10mg PO daily
      6. Nasal Saline Spray 1squirt per nostril BID and prn for nasal congestion
      7. Acetaminophen 500-1000mg Q 6 hours prn for fever and headache; Do not exceed more than 3 grams/day
   2. Non-Pharm
      1. Avoid environmental triggers as much as possible, especially tobacco smoke
      2. May utilize OTC chloraseptic spray and warm salt water gargles TID and prn for relief of sore throat.
      3. Continue to maintain adequate hydration with 8 glasses of water per day.
   3. Individualized Plan of Care
      1. Informed grandmother of available smoking cessation resources.
      2. Recommend annual influenza vaccine after resolution of acute illness.
   4. Diagnostics: Rapid Strep Test – negative
   5. Patient Education
      1. Continue OTC Zyrtec daily.
      2. Complete entire Medrol dose pack and taper as directed in the package.
      3. Proper administration of Flonase nasal spray provided. Administer to right nostril with left hand and left nostril with right hand while looking at the floor to avoid spraying medication directly onto nasal septum.
      4. Continue use of Albuterol inhaler as prescribed for shortness of breath and chest tightness; If rescue medication ineffective and your respiratory status continues to deteriorate report immediately to the urgent care or hospital.
      5. Symptoms should clear up with the adherence to the following medications, hydration, avoidance of allergens, and rest.
      6. If symptoms worsen or persist at time of follow up appointment will consider CBC with differential and broad-spectrum antibiotic therapy with Augmentin 875mg/125mg PO BID x 10 days. If symptoms persist or at time of resolution of illness will repeat pulmonary function testing and evaluate FEV1 and establish self-monitoring with peak expiratory flow rate meter.
   6. 
      Referrals
      
      : none at this time
   7. Follow up
      1. RTC in 3-5 days or PRN for any worsening symptoms, continued fever, green nasal drainage, persistent cough, or SOB.

Analysis of Comprehensive Assessment

S. R’s diagnosis was made on history and physical examination. As patient presented with a respiratory condition, the major systems considered for assessment were pulmonary, cardiac, HEENT, and abdominal. Because the patient has known asthma, asthma exacerbation was at the top of the differential list. However, after prodding, the practitioner realized that S.R had concurrent upper respiratory infection. First, the patient has a known history of allergies and her recent trip to the lake could have exacerbated her allergies, leading to an upper respiratory infection. Sinusitis was not considered due to the duration and the lack of facial tenderness on palpation. Strep throat was considered due to the sore, erythematous throat but ruled out due to negative rapid strep test. Upper respiratory infection diagnosis was attributed to allergic and viral causes. This diagnosis was supported with physical exam findings such as sore throat, fever, and congestion. Secondly, this is an exacerbation of her asthma due to exposure of allergen triggers second hand smoke exposure at home and upper respiratory infection. According to National Asthma Education and Prevention Program, upper respiratory infections are the most common cause of asthma attacks in children (2007). Patient woke up with chest tightness and audible wheezing. Diagnosis is further supported by supported by increased respiratory rate and diffuse expiratory wheezes upon auscultation.

Analysis of Comprehensive Plan of Care

Due to the diffuse wheezing heard during the physical exam, patient was given Albuterol 5mg NEB during the visit. This is done not only to relieve the wheezing, but also, to predict need for hospital admission (Kelly et al 2004). Pro-Air is a beta 2 agonist that is recommended for all patients with asthma for as needed use and patient was given a refill. S.R was also given oral corticosteroids due to incomplete response of the SABA during the night (2007). According to a cross sectional study, allergic rhinitis is associated with poor asthma control (de Groot et all, 2012). Due to her history of untreated allergies, patient was advised to continue the over the counter Zyrtec. Flonase and nasal saline spray were added to treat her rhinorrhea. Lastly for pharmacological interventions, patient was given Acetaminophen to provide symptomatic control for fever and headache. Non-pharmacological interventions include avoidance of triggers such as second-hand smoke as second-hand smoke exposure has been associated with increased likelihood of acute care visits for asthma and hospitalizations (Merianos 2017). Further, patient’s grandmother was given smoking cessation resources. Chloraseptic spray and salt water gargles were recommended to relieve sore throat and patient was encouraged to maintain hydration as fever and illness can cause dehydration. For individualized plan of care, influenza vaccine was recommended after resolution of acute illness. Rapid strep was performed due to sore and erythematous throat to rule out strep throat.

Patient was educated that the symptoms should clear up with the adherence to the following medications, hydration, avoidance of allergens, and rest. If symptoms worsen or persist at time of follow up appointment, the next step will be to consider CBC with differential and broad-spectrum antibiotic therapy with Augmentin 875mg/125mg PO BID x 10 days. If symptoms persist or at time of resolution of illness, the health care provider will repeat pulmonary function testing and evaluate FEV1 and establish self-monitoring with peak expiratory flow rate meter. As for patient education, extra education was provided to continue the over the counter Zyrtec due to the history of non-compliance. Patient and her grandmother were given education on following directions on the Medrol dose and on the importance of tapering the dose and how to administer the Flonase nasal spray. Important education was provided regarding the Albuterol nebulizer on when to administer and to report to an urgent care center or emergency department if ineffective. No referrals were given at this time and patient was advised to return in 3-5 days or earlier if needed to re-evaluate asthma symptoms and ensure patient’s condition is improving.

Summary Synthesis of the Encounter

Initially, I spent 20 minutes with the patient with history and physical. After hearing the bilateral wheezing, I informed my preceptor and suggested that the patient receive an office albuterol treatment. I also got a rapid strep test started during this period, My preceptor went in for evaluation and agreed with my plan. My goal to treat the acute problem first and then proceed with further treatment and I believe that was a strength during this encounter. After the patient finished her treatment, I went back to get the full history and finished my examination. After finishing my encounter, I discussed the case with my preceptor and told her my plan. My preceptor agreed with my plan and suggested that I add the chloroseptic spray for sore throat allergy medications. This plan was primarily made by me. Looking back, I realized that although I treated the major problem of asthma exacerbation, I failed to major trigger for the asthma exacerbation and am now aware for future interactions. I believe the plan is comprehensive.

Implications for NP practice

It is the policy of my current clinic to offer a flu shot to every patient that comes during flu season. However, flu vaccine screening it is especially important due to the risk for exacerbation. It was important that this patient receive her flu shot as soon as this exacerbation subsides. It is also important to educate the patient that steroids can weaken the vaccine and therefore it is important to wait until her steroid dose is completed (BTS/SIGN 2016). It is important to schedule a flu shot during her follow up in an effort to prevent the potential complication of further exacerbations. The use of a written asthma action plan is a concept that is utilized at my clinic. The action plan utilized at my clinic is symptom based versus peak flow based. A symptom-based asthma action plan has been proven to be more effective in prevent acute care visits (Zemek et al 2008). A written asthma action plan is not standard practice; however, due to the proven results of reduced acute care visits, this nurse practitioner student recommends this for practice change. My preceptor administers an in-office albuterol nebulizer to each patient that presents with an asthma exacerbation. Till now, I have questioned her decision to do that as all patients that came in did not have wheezing and this is not cost-effective. However, I realized now that it is protocol to do this to predict the need for hospitalization and ensure the patient is responding to the treatment (2017). It is vital for the NP to evaluate the use of the nebulizer and its effectiveness in order to prevent the potential complication of hospitalization.

It is not clinic policy to get a comprehensive history when patient presents for conditions such as this. However, as a result of a comprehensive history, this practitioner was able to identify the major trigger of second-hand smoke and provide resources for cessation (Merianos 2017). It is imperative that the nurse practitioner get a full history during acute asthma exacerbation visits in order to identify triggers as this can affect prognosis, prevention, and eventually cost-effectiveness in treating this disease.

References

• British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) (2016). British guideline on the management of asthma: a national clinical guideline.
  
  https://www.sign.ac.uk/sign-153-british-guideline-on-the-management-of-asthma.html
  
• de Groot, E.P., Nijkamp, A., Duiverman, E.J., & Brand P.L. (2012). Allergic rhinitis is associated with poor asthma control in children with asthma. Thorax, 67(7), 582-587. doi:10.1136/thoraxjnl-2011-201168
• Kelly, A.M., Kerr, D. & Powell, C. (2004). Is severity assessment after one hour of treatment better for predicting the need for admission in acute asthma? Respiratory medicine, 98(8), 777-781. doi:10.1016/j.rmed.2004.01.008
• Merianos, A.L., Jandarov. R.A., & Mahabee-Gittens, E.M. (2017). Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations. American journal of preventive medicine, 53(4), 441-448. doi:10.1016/j.amepre.2017.03.020
• National Asthma Education and Prevention Program. (2007). Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. The Journal of allergy and clinical immunology, 120(5 Suppl).
• Zemek, R.L., Bhogal, S.K., & Ducharme, F.M. (2008). Systematic review of randomized controlled trials examining written action plans in children: what is the plan? Archives of pediatrics & adolescent medicine, 162(2), 157-163. doi:10.1001/archpediatrics.2007.34