Running head: RESPIRATORY CLINICAL CASE 1 RESPIRATORY CLINICAL CASE 2 Respiratory Clinical Case Ram Pandey South University Online Dr. Judith Cornelius NSG 6001 Date: 04/08/2019 Patient Initials: CF Gender: Female Age: 65 Subjective Data Chief Complaint Patient comes to the clinic with the chief complaints of shortness of breath, wheezing and mild coughing. HPI For the last 2 months, patient has experienced asthma attacks on average more than 4 times a week, posttraumatic seizure 2 weeks after the accident and serious MVA 10 weeks ago. Anticonvulsant phenytoin started recently and there has not been any seizure activity since the initiation of therapy. PMH Patient has a history of periodic asthma attacks dating back to her early 20s. Three years ago, patient was diagnosed with mild congestive heart failure and placed on hydrochlorothiazide and sodium restrictive diet. Last year, CF placed on enalapril because of worsening CHF. Medication has controlled the symptoms relatively well the last year. Apart from enalapril, other medications prescribed for the patient include albuterol inhaler, theophylline SR capsules 300 mg PO BID, and PRN Phenytoin SR capsules 300 mg PO QHS. She has no known allergies. Patient has not had any surgeries. Family History The patient’s parents are both deceased. Her father succumbed to kidney failure at age 59 while her mother died of CHF aged 62 Social History Patient attests that she is a nonsmoker and she does not consume alcohol. She takes four cups of diet colas and the same number of coffee cups ROS Positive for cough, wheezing, exercise intolerance and shortness of breath. Denies seizures, headaches and swelling of extremities Gen Pale, well-developed Caucasian female appearing to be anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Abdomen: non-tender, soft, non-distended no masses. Chest: Bilateral expiratory wheezes. Cardio: Regular rate and rhythm normal S1 and S2. Rectal: Guaiac negative. GU: Unremarkable. NEURO: A&O X3, cranial nerves intact. EXT: +1 ankle edema, on right, no bruising, normal pulses. Objective Data Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”. After the albuterol treatment, vital signs are BP 134/79, HR 80, and RR 18 Physical Assessment and Diagnostic Testing: Na – 134, K - 4.9, Cl – 100 (all within normal limits), BUN – 21, Cr - 1.2, Glu – 110, Theophylline - 6.2, Phenytoin – 17, ALT – 24, AST – 27, Total Chol – 190 (substantially high, predicted moderate restriction). CBC – WNL, Chest Xray – Blunting of the left and right costophrenic angles, Peak Flow – 75/min (relatively low, normal should be between 80-100/min); after albuterol – 102/min, FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% (predicted moderate obstruc.

1. Running head: RESPIRATORY CLINICAL CASE
1
RESPIRATORY CLINICAL CASE
2
Respiratory Clinical Case
Ram Pandey
South University Online
Dr. Judith Cornelius
NSG 6001
Date: 04/08/2019
Patient Initials: CF Gender: Female Age:
65
Subjective Data
Chief Complaint
Patient comes to the clinic with the chief complaints of
shortness of breath, wheezing and mild coughing.
HPI
For the last 2 months, patient has experienced asthma attacks on
average more than 4 times a week, posttraumatic seizure 2
weeks after the accident and serious MVA 10 weeks ago.
Anticonvulsant phenytoin started recently and there has not
been any seizure activity since the initiation of therapy.
PMH
Patient has a history of periodic asthma attacks dating back to
her early 20s. Three years ago, patient was diagnosed with mild
congestive heart failure and placed on hydrochlorothiazide and

2. sodium restrictive diet. Last year, CF placed on enalapril
because of worsening CHF. Medication has controlled the
symptoms relatively well the last year. Apart from enalapril,
other medications prescribed for the patient include albuterol
inhaler, theophylline SR capsules 300 mg PO BID, and PRN
Phenytoin SR capsules 300 mg PO QHS. She has no known
allergies. Patient has not had any surgeries.
Family History
The patient’s parents are both deceased. Her father succumbed
to kidney failure at age 59 while her mother died of CHF aged
62
Social History
Patient attests that she is a nonsmoker and she does not
consume alcohol. She takes four cups of diet colas and the same
number of coffee cups
ROS
Positive for cough, wheezing, exercise intolerance and shortness
of breath. Denies seizures, headaches and swelling of
extremities
Gen
Pale, well-developed Caucasian female appearing to be anxious.
HEENT: PERRLA, oral cavity without lesions, TM without
signs of inflammation, no nystagmus noted. Abdomen: non-
tender, soft, non-distended no masses. Chest: Bilateral
expiratory wheezes. Cardio: Regular rate and rhythm normal S1
and S2. Rectal: Guaiac negative. GU: Unremarkable. NEURO:
A&O X3, cranial nerves intact. EXT: +1 ankle edema, on right,
no bruising, normal pulses.
Objective Data
Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’
3”. After the albuterol treatment, vital signs are BP 134/79, HR
80, and RR 18
Physical Assessment and Diagnostic Testing: Na – 134, K - 4.9,
Cl – 100 (all within normal limits), BUN – 21, Cr - 1.2, Glu –
110, Theophylline - 6.2, Phenytoin – 17, ALT – 24, AST – 27,

3. Total Chol – 190 (substantially high, predicted moderate
restriction). CBC – WNL, Chest Xray – Blunting of the left and
right costophrenic angles, Peak Flow – 75/min (relatively low,
normal should be between 80-100/min); after albuterol –
102/min, FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% (predicted
moderate obstruction).
Assessment
1. Chronic obstructive asthma J44.9 (CMS.gov, 2016).
Presenting symptoms that match this diagnosis include
wheezing, cough, dyspnea/shortness of breath, cough and +1
ankle edema. Previous asthma attacks also place the patient at
increased risk of contracting chronic obstructive asthma
2. Emphysema, unspecified J43.9 (CMS.gov, 2016), as
evidenced by the patient’s shortness of breath, cough, low
FEV1/FVC 60%
3. Bronchitis not specified as acute or chronic. J40 (CMS.gov,
2016) as indicated by the occasional cough, shortness of breath
and bilateral expiratory wheezes
Care Plan
A comprehensive care plan targeting the identified diagnoses
will help in improving patient care outcomes for the 65-year-old
Caucasian female. Patient must receive appropriate instruction
pertaining to the possible diagnoses identified. Asthma can be a
life threatening condition that causes inflammation and swelling
of the airways, making it difficult to breathe. Environmental
and genetic factors may play a role in asthma attacks. Bellia &
Incalzi (2012) contend that other risks such as air pollution,
stress and allergies can trigger asthma attacks. Emphysema on
the contrary is a lung disease characterized by reduced airflow
and inflammation in the lungs. The reduced airflow results in
gradual destruction of the small sacs in the lungs, subsequently
manifesting symptoms such as shortness of breath, chest
tightness, fatigue, a chronic cough and wheezing. Major risk
factors for developing emphysema include smoking, exposure to
air pollution and alpha-1-antitrypsin (ATT) deficiency (Buttaro,

4. Trybulski, Bailey, & Sandberg-Cook, 2013). Bronchitis is also a
serious lung disease that occurs due to bronchial tubes’
inflammation. The most common cause of the condition is cold
virus, but bacteria can also be the cause in some cases.
The treatment plan prioritizes medications as well as other non-
pharmacological interventions. Anticipated outcomes include
patient demonstrating improved oxygenation and ventilation,
exhibiting effective breathing patterns, maintaining respiratory
rate within normal limits and increased control of inflammatory
episodes. According to Buttaro et al. (2013), the first line
medication for asthma is albuterol, inhaled 1 to 2 puffs every 4
to 6 hours when the patient has breathing complications.
Similarly, for emphysema, the primary medication used for
reducing dyspnea and improving exercise tolerance is albuterol.
Dosage approved by the FDA is 400 µg inhaled twice daily
(Bellia & Incalzi, 2012). Other medications to prescribe to the
patient will include metaproterenol and levalbuterol (0.2 to 0.3
mL of 5% solution). The medications target various reversible
airflow limitations including bronchial smooth muscle
contraction, increased airway secretions, bronchial mucosal
congestion and airway inflammation. Various medications are
also effective for treating bronchitis. Apart from albuterol, the
other effective drug for managing the condition is amoxicillin
80 to 90 mg per kg per day taken orally.
Complementary and alternative medicines will also be part of
the care plan. Various studies have indicated the efficacy of
some herbal remedies in the management of pulmonary
conditions such as asthma, bronchitis and emphysema. For
example, in a study conducted by Akinci, Zengin, Yildiz, Sener,
& Gunaydin (2011), the researchers found out that the most
common and effective CAM methods utilized by the participants
included deep inhalation, applying vapor, praying and herb or
herbal tea. Generally, the patients in this study used CAM to
relax, reduce dyspnea, breath comfortably and improve

5. respiration. The researchers also established that these CAM
methods had little to no negative side effects (Akinci et al.,
2011). Because of the efficacy and safety of the herbal
remedies, practitioner will consult with patient to ascertain
whether she could implement any of the methods in combination
with the medications prescribed. Consulting with the patient
also aids practitioner to provide culturally congruent care.
Patient will also receive education on self-care practices that
can aid to improve her condition. As the European Respiratory
Society (2013) points out, self-care should entail avoiding
secondhand smoke, avoiding smoke from fireplaces and
avoiding exposure to very cold air. It is also paramount to
instruct the patient about the proper use of cough suppressants,
OTC fever reducers and pain relievers. Practitioner will further
enlighten the patient about the importance of using forward-
leaning postures in addition to learning controlled breathing
techniques such as purse-lip breathing and abdominal muscle
breathing (diaphragmatic breathing). Practitioner will also
evaluate the patient’s knowledge pertaining to the use, care and
cleansing of nebulizer and inhaler use. According to Bellia &
Incalzi (2012), contaminated DPIs, MDIs, diskus, turbuhaler
and nebulizer equipment are typical causes of infections.
Apart from the practitioner, other helping professionals will
also provide care to the patient. For example, human service
professionals will help patient in looking for possible
assistance/community resources while spiritual leaders will
offer nourishment to ensure that the patient receives holistic
care. Referring the patient to psychiatric specialists is another
component of the care plan that will help ease her anxiety and
mild stress. Involving CF’s family members is also critical.
Buttaro et al. (2013) acknowledge that warmth and cohesiveness
in the family environment improves resiliency and provides a
coping mechanism for the patient.
Follow-Up Plan
Follow-up will entail appropriate monitoring of patient’s vital

6. signs following discharge. First follow up scheduled after 4
weeks. During the session, practitioner will conduct
comprehensive physical examinations and diagnostic tests
including spirometry, methacholine challenge test and chest x-
rays to check the prognosis of disease (European Respiratory
Society, 2013). Patient to share information about any side
effects or allergies associated with the medications she is
taking. Appropriate measures will be taken to ensure adherence,
compliance and improved outcomes.
References
Akinci , A., Zengin , N., Yildiz , H., Sener , E., & Gunaydin ,
B. (2011). The complementary and alternative medicine use
among asthma and chronic obstructive pulmonary disease
patients in the southern region of Turkey. International Journal
of Nursing Practiceq, 17(6), 571-582.
Bellia, V., & Incalzi, R. (2012). Respiratory diseases in the
elderly (3 ed.). Sheffield: European Respiratory Society
Journals.
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J.
(2013). Primary care : a collaborative practice (4 ed.). St.
Louis, Mo.: Elsevier/Mosby.
CMS.gov. (2016). ICD-10. Retrieved from
https://www.cms.gov/medicare/coding/icd10/index.html
European Respiratory Society. (2013). Respiratory diseases in
the world: Realities of today – opportunities for tomorrow.
Retrieved February 12, 2017, from
https://www.ersnet.org/pdf/publications/firs-world-report.pdf
Running head: NAME OF CARE PLAN 1

7. Title of Plan of Care
Name
South University Online
Faculty Name
NSG 6001
Date

8. NAME PLAN OF CARE 2
**Please delete this statement and anything in italics prior to
submission to shorten the length
of your paper.
Patient Initials ______
Subjective Data: (Information the patient tells you regarding
themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in
chronologic order using symptom
analysis [onset, location, frequency, quality, quantity,
aggravating/alleviating factors, associated
symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why
taking, allergies, other major
medical problems, immunizations, injuries, hospitalizations,
surgeries, psychiatric history,
obstetric and history sexual history).
Significant Family History: (Includes family members and
specific inheritable diseases).

9. Social History: (Includes home living situation, marital history,
cultural background, health
habits, lifestyle/recreation, religious practices, educational
background, occupational history,
financial security and family history of violence).
Review of Symptoms: (Review each body system - This section
you should place POSITIVE for…
information in the beginning then state Denies…). - General:;
Integumentary:; Head:; Eyes: ;
ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:;
Genitourinary:; Musculoskeletal:;
Neurological:; Endocrine:; Hematologic:; Psychologic: .
Objective Data:
Vital Signs: BP - ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe
review)
HEENT:
Lymph Nodes:
Carotids:
Lungs:
Heart:

10. Abdomen:
Genital/Pelvic:
Rectum:
Extremities/Pulses:
Neurologic:
Laboratory and Diagnostic Test Results: (Include result and
interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10
codes. Please place in order of
priority.)
Plan of Care: (Addressing each dx with diagnostic and
therapeutic management as well as
education and counseling provided).
NAME PLAN OF CARE 3
References
Week 2: Respiratory Clinical Case

11. Patient Setting:
65 year old Caucasian female that was discharged from the
hospital 10 weeks ago after a motor vehicle
accident presents to the clinic today. States she is having severe
wheezing, shortness of breath and
coughing at least once daily. She can barely get her words out
without taking breaks to catch her breath
and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4
times per week average), serious MVA 10
weeks ago; post traumatic seizure 2 weeks after the accident;
anticonvulsant phenytoin started – no
seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild
congestive heart failure diagnosed 3 years ago;
placed on sodium restrictive diet and hydrochlorothiazide; last
year placed on enalapril due to
worsening CHF; symptoms well controlled the last year.

12. Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN;
Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of
coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA
ROS
Positive for shortness of breath, coughing, wheezing and
exercise intolerance. Denies headache,

13. swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment - BP 134/79, HR 80, RR
18
Gen: Pale, well developed female appearing anxious. HEENT:
PERRLA, oral cavity without lesions, TM
without signs of inflammation, no nystagmus noted. Cardio:
Regular rate and rhythm normal S1 and S2.
Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-
distended no masses. GU:
Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema,
on right, no bruising, normal pulses.
NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing
Na - 134
K - 4.9
Cl - 100
BUN - 21
Cr - 1.2

14. Glu – 110
ALT – 24
AST - 27
Total Chol – 190
CBC - WNL
Theophylline - 6.2
Phenytoin - 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%