A 25-year-old G1 P1 patient arrives with her husband for her office visit. She states she delivered her daughter 3 months ago and since then she, the patient, cries all day, cannot sleep, and has no energy. Her husband has taken over most of the care of the baby, but must return to work. She stopped nursing. Her physical exam is negative. 1. Prioritize what additional questions you must ask this patient? 2. What is your differential diagnosis? 3. Will you obtain laboratory screening, yes/no and explain rational. 4. What treatment will you prescribe? 5. What referrals/consults will you schedule? 6. What education will you provide? Please use references that are US Based and can be found on line, peer reviewed, and evidenced based
A 52 y/o white female presents with three days history of shortness of breath, worse at night, and with exertion. She is employed at a clothing factory as supervisor for cloth dying. She states that over the last one week she has had worsening cough that has precipitated into yellow sputum. She has h/o asthma, in which she uses an inhaler three-four times weekly, unknown to her and for the few days she has been using it every few hours without relief. Also she has history of steroids use with some relief but she does not remember the last time. She stopped smoking 10 years ago. The vital signs were BP 144/80 (slightly raised); Pulse 108 (tachycardia); Respiratory Rate 28 (raised); Temperature 101.6 (febrile).
¢ Severe asthmatic attack
1. What history questions would you ask this patient?
¢ Do you experience inabilities in speaking in full sentences? Most patients with severe asthmatic attacks are unable to speak in full sentences (Holgate & Douglass, 2010); this question is asked to confirm the diagnosis and rule out any other condition.
¢ How long have you coughed? This question is asked to rule out any other underlined condition that could be as a result of coughing for instance pneumonia, bronchitis, and TB.
¢ When do you experience breathlessness? Do you experience breathlessness while lying down? This question is asked to rule out any other type of asthmatic attack and confirm the diagnosis. Patients with severe asthmatic attack will experience breathlessness even while lying down unlike other types (Landau, 2009).
¢ When experiencing breathlessness, what are the exacerbating and relieving factors? This is to confirm the diagnosis and plan for the management.
¢ Are you able to bring sample of the inhaler that you have been using? And which steroids have you been using? Asked to get the clear picture of the inhaler the patient has been on since she does not know and to know the exact steroids she has been on. This is for the clear plan of her management.
¢ Are you on any other medications apart from the ones you have mentioned? The question is asked to evaluate if the patient is on any other drugs that could interfere with asthmatic treatment or that could worsen the condition or that could interfere with the medications to be given (Catrambone, Follenweider & Krau, 2013).
¢ How frequent do you take them?
¢ Can you demonstrate to me how you make use of your inhaler? This question is asked to evaluate if the patient knows how to use the inhaler or she uses it in the wrong way.
¢ Apart from the challenges you have mentioned about the inhaler, are you having any other problems with your medications? To find out if the patient is compliant to the drugs or if she is having any other complications with the drugs (Catrambone, Follenweider & Krau, 2013.
¢ How often do you seek medical care and under which circumstances? This question is asked to the patient to find out how often the patient seeks medical care.
2. What tests, if any, would you order?
¢ Pulmonary function test for instance peak expiratory flow, oxygen saturation, spirometry, Nitric oxide measurements, and pulse oximetry; this test is to deduce the integrity of the lungs(Li, 2013).
¢ Allergy Tests for Asthma; this is to detect the allergens since almost anything can trigger an allergic reaction (Li, 2013).
¢ Chest X-ray as well as arterial blood gases (ABGs) should be performed for further management of the patient.
3. Would you order any medication for this patient to be given in the office?
IV magnesium sulfate stat, with this regard a single dose of intravenous magnesium sulfate has been shown to be safe, and is effective in some patients with acute severe asthma who have not had a good response to initial treatment (Li, 2013).
4. What medication(s) if any would you prescribe for this patient if any, support your decision with scientific rationale?
The principles of treatment for a severe attack of asthma are the same for both adults and children (Li, 2013). For my case, I will
¢ Administer oxygen to maintain oxygen saturation (SpO2) above 95%,
¢ Nebulizers driven by oxygen at 8 l per minute are most commonly used to administer bronchodilators for many reasons, incorporating simultaneous oxygen administration.
¢ IV salbutamol as well as monitoring potassium levels carefully as hypokalaemia occurs with high doses of beta2 agonists.
5. Create a list of differential diagnosis.
¢ Cough-Variant asthma
¢ Sinus Infection
¢ Smoking Cessation
6. What education would you provide this patient regarding her symptoms and her disease process? (pattern is uploaded)
Entirely, asthmatic attacks require immediate treatment with a quick-acting inhaler for instance albuterol. Therefore the patient will be required to avoid your triggers; minimize the exposure to them; frequent washing of hands to reduce your risk cold virus; always cover the face with a mask or scarf during cold (Catrambone, Follenweider & Krau, 2013).
Catrambone, C. D., Follenweider, L. M., & Krau, S. D. (2013). Asthma. Philadelphia, PA: Elsevier.
Holgate, S. T., & Douglass, J. A. (2010). Asthma. Abingdon: HEALTH Press.
Landau, E. (2009). Asthma. Tarrytown, N.Y: Marshall Cavendish Benchmark.
Li, J. (2013). Pharmacotherapy of Asthma. Hoboken: Taylor and Francis.