Subjective Data:
Patient’s demographic and social information
Jnr. is a 10 year old African American Male patient brought into clinic by his mother who reports that Jnr. was recently discharged from hospital for acute asthma exacerbation. The boy presented with cough and difficulty in breathing combined with a running nose and elevated temperature which has now been resolved with over the counter Tylenol. The mother also says that her son has a history of multiple admissions to the hospital for acute asthma exacerbation. His mother reports child repeatedly loses inhalers. She also states that she does not check for inhaler nightly, and the child can go for weeks, hiding the fact that he lost inhaler.
History of present illness
Jnr. started experiencing a cough about three days ago and it has only gotten worse until he was put under Tylenol. The cough broke out approximately two weeks after his discharge from the hospital. The cough persisted, and last night, he experienced difficulties in breathing. The condition was managed with over-the-counter Tylenol. Jnr. reports that he is no longer in much pain as he was before the medication. According to his mother, he has had recurrent aggravation of the asthmatic symptoms because of his irregular use of the inhaler, as he often loses it.
Relevant past medical history
Asthma
Positive for sleep apnea
Bronchiolitis at 8 month required no medication or hospitalization
Relevant past surgical history
Jnr. has never had a medical condition that required surgery
Family history
Mother: diabetes, hypertension, and depression
Father: obesity
Sibling: healthy
•Review all of systems: Subjective Data
General: The patient experiences severe coughs especially during the night, which makes it difficult for him to sleep throughout the night. He also experiences shortness of breath, combined with tightness of the chest when he engages in physically-demanding activities. The mother admits that the symptoms flare if the patient encounters dust
Cardiovascular: Mother reveals that the patient has never been treated for any cardiovascular disease, although they have been told that he is at a greater risk of acquiring a cardiovascular disease die to his asthmatic condition. For this reason, the mother ensures a healthy diet and physical fitness.
-Skin: Patient reports a hand injury acquired when playing. However, the injury was fixed at home with an antiseptic and bandage, as it was not a deep cut.
-Respiratory: patient admits to experiencing breathlessness, especially during play time and at night. His mother reports that he also gets a snorting sound several times during the night (sleep apnea). During the breathless moments, the patient also experiences pain in the chest.
-Eyes: Patient reports itchy eyes, but his vision is 20/20 since his last optical visit. The mother ensures that he visits an optician at least once a year
-Gastrointestinal: The patient is reported to frequently experience indigestion, a burning sensation below his diaphragm, and regurgitations.
-Ears: The patient had repeated occurrences of ear infections during his infancy, but mother says the last infections he had, was when he was 3 years old. He does not feel pain or discomfort in the ears now.
-Genitourinary /Gynecological: No history of urinary tract and/or reproductive organs infections
-Nose/Mouth/throat: The patient’s nose is mostly blocked, forcing him to breathe through his mouth. A thin colorless secretion comes out of the nose. He reports no lacerations or injuries in the mouth, although his throat is mostly scratchy and itchy.
-Musculoskeletal: patient has no history of musculoskeletal disorders, and reports no pain or discomfort in the musculoskeletal system
-Breast: No history or current indications of infections or diseases of the breast
-Neurological: The patient has no history of neurological disorders
_Heme/Lymph/Endo: None
-Psychiatric: Sleep apnea
Objective information
-General: Patient is able to answer most of the questions on his own, although between coughs
-Cardiovascular: elevated heartbeat
-Skin: No dryness on skin, wound healing fine
-Respiratory: Patient seems to be taking labored breaths, and is wheezing
-Eyes: eyes are red, patient scratches often.
-Gastrointestinal: Hiccups
-Ears: No infection observed, ears are clean
-Genitourinary /Gynecological: Patient handles defecation and urination without problem
-Nose/Mouth/throat: Running nose, coughs, and frequent clearing of the throat
-Musculoskeletal: Patient is able to move and stand independently
-Breast: No signs of breast infection
-Neurological: When the coughs attack, patient curls his hands, such that he is unable to draw or write
_Heme/Lymph/Endo: Lymphatic and endocrine are functioning well.
-Psychiatric: Patient appears tired and sleepy
Initial Differential Diagnoses (3)
Bronchiolitis: Asthma, Aspiration syndromes, and bacterial pneumonia.
Asthma: Foreign body aspirations, pneumonia, and cystic fibrosis (CDC, 2015)
GERD: Acute gastritis, Hiatal hernia, and helicobacter pylori infection.
-Objective data:
The CDC (2011) recommends physical examinations as part of asthma diagnosis, since it allows the doctor to carry out a comprehensive check on the patient. For pediatric patients, the physical examination includes evaluating the ears, eyes, heart, lung, abdomen, skin, and general health
CBC test was ordered for the patient, as according to Ege et al. (2011), it is effective in checking for a variety of health conditions that cause symptoms similar to those of asthma. The test is also comprehensive in determining the overall health status of a patient, and it is tolerable among children (Fitzpatrick et al., 2011).
A BMP test was also carried out, with the aim of determining the balance of electrolytes in the body. Electrolyte imbalance can cause breathlessness and tiredness, which are symptoms of asthma (CDC, 2011). EKG test was also done, as it reveals presence of pulmonary embolus, which may cause breathlessness and chest pains (NIH, 2015). T4 and TSH tests were done to examine the functioning of the thyroid, and rule out any abnormalities of the gland. A1c test was done to rule out diabetes, considering his mother has the condition.
Recommend chest x-ray: (referral)
Additionally, the patient was referred for a radiography, which further reveals any other causes of wheezing, hence contributing to making the proper diagnosis (Baye et al., 2011)
•Initial impression or refined differential diagnoses:
-Further labs or other testing indicated; consultations/referrals needed
The initial impression about the condition of the patient was Bronchiolitis. However, the patient was referred for further imaging, which showed that the bronchi weren’t obstructed by edema, but rather, by constriction of the bronchi (CDC, 2015). From the subjective data, it is also evident that the exacerbation occurs after encounters with dust, and during exertive physical exercises. NIH (2015) recommends avoidance of triggers in effectively managing the condition. Also, it is important that the patient educated on the importance of adherence.
Results of additional testing (we will make all labs pending and have patient return to clinic for review of lab results and further treatment intervention.
Primary diagnosis is asthma. Differential diagnosis is bronchiolitis
The patient is advised to avoid triggers, in addition to the prescription medications (CDC, 2015):
Leukotriene Modifiers (zafirlukast), 5mg taken orally once every day, in the evening. Dispensed from the pharmacy, 15 tablets per dispensation. Generics may be substituted
Beta-agonists, (albuterol), to be used when the symptoms flare up through inhalation. The medication will be dispensed via a pharmacy, one inhaler at a time.
Describe specific education provided regarding problem and related health promotion, follow-up schedule, etc.
-medication: Enlightened the patient on the importance of adhering to the medications, and especially in taking care of the inhaler, which helps in managing flare-ups. Also advised the mother on the side effects that she should look out for in her son, including the risks -
Evaluation and Revisions:
A follow-up visit was requested with the patient in two weeks’ time to assess the progress and reaction to the interventions
Summary of Articles
Baye et al. (2011) carried out a study to establish the correlation between genes and asthma, specifically in African American and European children. The results of the study indicate that genetics play a critical role in the development of asthma. This article is of importance to this study, as the patient is an African American. Similarly, Smith and Nriagu (2011) sought to establish the factor that predispose African American children in Michigan to asthma, and found that exposure to lead is one of the predisposing factors. This information was informative when ordering tests for the patient. Ege et al. (2011) sought to establish the relationship between children’s exposure to microorganisms and the development of asthma. The results showed that children who are exposed to microorganisms that trigger asthmatic reactions are more protected against asthma, compared to children who are not exposed. When the body is exposed to microorganisms, it develops natural defenses, which consequently prevents development of reactions such as asthma.
Fitzpatrick et al. (2011) acknowledges that asthma in children is a varied disorder, as the symptoms present differently, hence requires different treatment methods. This article is significant to the case study, as it provides information on the different variations of asthma in children, including how the variations can be effectively managed. Diagnosis of asthma in children is challenging to practitioners, as there are other conditions that present with similar symptoms. Savenije, Kerkhof, Koppelman and Postma (2012), provides an overview of how the prediction rule, using patient history, can be used to make a proper diagnosis.
References
Baye, T. M. et al. (2011). Differences in candidate gene association between European ancestry
and African American asthmatic children. PLoS One, 6(2), e16522.
Centers for Disease Control and Prevention,CDC. (2011). Vital signs: asthma prevalence,
disease characteristics, and self-management education: United States, 2001—2009.
Morbidity and Mortality Weekly Report, 60(17), 547.
Centers for Disease Control and Prevention, CDC. (2015). What is asthma? Retrieved January
23, 2016, from http://www.cdc.gov/asthma/faqs.htm
Ege, M. J. et al. (2011). Exposure to environmental microorganisms and childhood asthma. New
England Journal of Medicine, 364(8), 701-709.
Fitzpatrick, A. M. et al. (2011). Heterogeneity of severe asthma in childhood: confirmation by cluster analysis of children in the National Institutes of Health/National Heart, Lung, and
Blood Institute Severe Asthma Research Program. Journal of Allergy and Clinical
Immunology, 127(2), 382-389.
National Institutes of Health, NIH. (2015). How is asthma treated and controlled. Retrieved
Savenije, O. E., Kerkhof, M., Koppelman, G. H., & Postma, D. S. (2012). Predicting who will
have asthma at school age among preschool children. Journal of Allergy and Clinical
Immunology, 130(2), 325-331.
Smith, P. P., & Nriagu, J. O. (2011). Lead poisoning and asthma among low-income and African
American children in Saginaw, Michigan. Environmental Research, 111(1), 81-86.
