Patient Information

Patient Information:
M.G., 40-year-old female, race unknown, insurance unknown.
(S) Subjective:
CC: “I think I may have a cold. I’ve been having a hard time breathing on and off lately.”
HPI: “I notice I’m short of breath mostly at work but by the time I get home feel fine. No episodes of shortness of breath on the weekends that I can recall. But a few hours back at work and I start to feel like I cannot catch my breath again. A few months ago this happened and it was so bad I left work and went to urgent care where they gave me a breathing treatment of some kind and sent me home on an antibiotic. I would like you to give me another antibiotic. She denies sputum. No new allergy triggers noted. She denies heartburn.

PMHx: Reports good health. Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist ten years ago, Took allergy shots for five years with great results, now only takes Zyrtec when needed.
Childhood/previous illnesses: eczema
Surgeries: Tonsillectomy, Cholecystectomy
Hospitalizations: childbirth x 3.

Immunizations: up-to-date on all vaccinations.

Other Screenings: Not reported.

Allergies: Strawberries-Rash; erythromycin- severe GI upset. Seasonal allergies- worse in the spring
Blood transfusions: none
Current medications: Multivitamin, Zyrtec
Social History: Married, lives with husband and 3 children. Worked in advertising up until 18 months ago when she got laid off. In order to help with the household finances she took a job as a Baker’s assistant at an Artisan Bread Bakery. She arrives at 4 a.m. every morning to begin baking breads/pastries for the day.
Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20’s. Denies illicit drug use.

Sleeps 6 to 7 hours a night. Exercises four to five days per week.

Family History: Children are healthy- daughter currently has a sinus infection. Parents are deceased. Mother at age 80 from congestive heart failure. Father died at age 82 from lung cancer, diagnosed when metastasized to brain. PGM: died from unknown causes, PGF: Stroke at age 82. MGM: died at 83, had HTN, atherosclerosis and many heart attacks. PGF: died at 71 from complications of COPD.

CONSTITUTIONAL: No reports of fever, chills, weight loss.
HEENT: None reported.
CARDIOVASCULAR: None reported.
RESPIRATORY: Shortness of breath at work. Denies sputum.
GASTROINTESTINAL: Denies heartburn.
GENITOURINARY: None reported.

NEUROLOGICAL: None reported.
INTEGUMENT: None reported.

PSYCHIATRIC: None reported.
ENDOCRINOLOGIC: None reported.
ALLERGIC/IMMUNOLOGIC: Seasonal allergies- worse in spring
 (O) Objective:
Vital signs: B/P 130/70, T 98.0, HR 75, RR 18 Sao2 98% RA.

Height 5’10”
Weight 140 pounds
BMI: 20.1
GENERAL: 40-year-old Caucasian female, dressed in work clothes. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless.
HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.

EYES: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.

Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender
NOSE: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses non-tender to palpation.

THROAT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.

RESPIRATORY: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight wheezing noted inspiration and on forced expiration. Wheezing does not clear with forced cough.

CARDIOVASCULAR: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema
ABDOMEN: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.

SKIN: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.

Diagnostic results:
Pulmonary Function Testing:
Pre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreased
Post Bronchodilator Challenge- FEV1/FVC 75%
Pulse oximetry is 98%
Will refer for allergy testing.

(A) Assessment:
Moderate Persistent Asthma, uncomplicated: J45.40
The pulmonary function test (PFT) reveals reversible airway obstruction. The level of severity should be assigned to the most severe category in which any feature is present (Buttaro, Trybulski, Polgar-Bailey, & Sandburg-Cook, 2017 and NAEEP, 2007). Lung function test reveal pre-bronchodilation FEV1/FVC 60% indicating obstruction and post bronchodilator challenge FEV1/FVC 75%, showing a greater than 12% increase demonstrating this is a reversible obstruction (McCracken, et al., 2017). The reversibility of airway obstruction is indicated by an increase in FEV1 of 12% or greater from baseline after inhalation of short-acting ?2-agonists (McCracken, et al., 2017). A measurement of FVC/FEV1 less than 80% but greater than 60% is considered moderate on the classification of asthma severity (Buttaro, Trybulski, Polgar-Bailey, & Sandburg-Cook, 2017).

Michelle completed pulmonary function test with the following results: Pre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreased and Post Bronchodilator Challenge- FEV1/FVC 75%, showing a 15% increase, demonstrating a reversible obstruction.
Clinical hallmarks of asthma include episodic wheezing with dyspnea, cough and sputum production (McCracken, et al., 2017). M.G.’s chief complaint is feeling like she can’t catch her breath (dyspnea), which is a clinical hallmark of asthma (McCracken, et al., 2017). Physical exam reveals Slight wheezing noted inspiration and on forced expiration. Wheezing does not clear with forced cough
Occupational exposure to unspecified risk factor: Z57.9
A typical history of occupational asthma includes the presence or worsening of asthma symptoms at work and their disappearance or improvement away from work (Vandenplas, et al., 2017). M.G. states “I notice I’m short of breath mostly at work but by the time I get home feel fine. No episodes of shortness of breath on the weekends that I can recall. But a few hours back at work and I start to feel like I cannot catch my breath again”. The exact cause is not known until allergy testing is completed to confirm the allergen(s).

Allergic Rhinitis: J30.9
Physical exam reveals Nares patent with thin white exudate noted. Mucosa appears boggy and pale. According to Holmes & Scullion (2015), the provider should look for signs of boggy mucosal swelling, a horizontal nasal crease across the dorsum of the nose (in severe rhinitis), caused by the ‘allergic salute’, which are typical signs associated with allergic rhinitis. M.G. reports seasonal allergies, which is worse in the spring.

Allergic rhinitis often co-exists with asthma and if it is not treated, it can cause poor asthma control (Holmes & Scullion, 2015).

Elevated Blood Pressure: R30.0
Blood pressure at today’s visit is 130/70. 2017 Guidelines for High Blood Pressure in adults states Stage 1 Hypertension is 130-139 or 80-89 mm Hg, two readings are needed on separate occasions (Whelton ; Carey, 2018).

(P) Plan:
Levalbuteral HFA 45mcg
Sig: 2 puffs q4-6h PRN,
Disp: 1, Refills: 2
All patients with asthma should have a rescue inhaler, which is a short-acting beta 2-agonist (McCracken, et al., 2017). First line treatment would include an inhaled short-acting beta 2-agonist (SABA) such as albuterol (McCracken, et al., 2017). SABA provides rapid relief by reducing airway narrowing and associated symptoms of cough, chest tightness, and wheezing by relaxing the smooth muscle within the airway walls (McCracken, et al., 2017). For acute attacks, only albuterol should be used to relieve severity of symptoms (McCracken, et al., 2017).

Budesonide DPI 90 ug
Sig: 2 puff inhaled twice a day
Disp: 1 Refills: 1
Moderate persistent asthma should start with Step 3 in the stepwise approach and includes a medium-dose inhaled corticosteroid (ICS) or a combination of low-dose ICS and a long-acting beta 2 agonist (LABA) (McCracken, et al., 2017). An alternative treatment plan would include a low-dose ICS and a Leukotriene receptor antagonists (LTRAs) (McCracken, et al., 2017). Due to the cost of inhalers, I chose to least expensive route, the alternative treatment requiring only 1 additional inhaler. The exact mechanism of ICS is not exactly understood but is believed to reduce inflammatory mediators and inhibit late responses to allergens affecting airway (Buttaro, et al., 2017).
Singulair 10 mg
Sig: Take 1 tablet by mouth once a day
Disp: 30 Refills: 2
This is the LTRA I decided to prescribe to complete the Step 3 approach. An oral leukotriene receptor antagonist (LTRA) may be as effective as inhaled corticosteroids and is an alternate first-line treatment and these medications work by blocking the action of cysteinyl leukotrienes, key mediators of airway smooth muscle contraction (McCracken, et al., 2017). LTRAs decrease sputum production, airway edema, and promote persistent bronchodilation (Buttaro, et al., 2017). Singular (LTRA) may also treat allergic rhinitis, but is not a first line treatment for allergic rhinitis (Gorroll ; Mulley, 2014).

Zyrtec 5 mg
Sig: Take 1 tablet by mouth once a day
Disp: 30 Refills: 5
Zyrtec is a second-generation antihistamine and is a first line treatment for allergic rhinitis (Ayer ; Altman, 2014). Histamine is released during early allergic response and the use of an antihistamine reduced histamine activated secretions and anti-inflammatory effects (Holmes ; Scullion, 2015).
Centrum Women Multivitamin
Sig: Take 1 tablet by mouth once a day
Disp: 30 Refills: 5
Teach diagnosis of asthma. Clinicians should ensure patients and families understand the basic facts about asthma (especially the role of inflammation), medication skills, and self-monitoring techniques (NAEEP, 2007).

Review each medication, why its used, and side effects; teach patient to bring all medications to follow up appointments (NAEEP, 2007).
Frequent use of short-acting inhaler is a sign that asthma is not well controlled (McCracken, et al., 2017).

Rinsing of the mouth is recommended with the ICS to prevent thrush (McCracken, et al. 2017).

Inhaler technique: Teach and as M.G. to return demonstration of inhaler technique would be optimal prior to leaving the office to ensure appropriate technique and determine if a spacer is needed, and if so, how to use the spacer (McCracken, et al., 2017). Rinsing of the mouth is recommended with the ICS to prevent thrush (McCracken, et al. 2017).

Asthma Action Plan (AAP): If persistently in the yellow zone on her AAP, she should be educated to seek medical advice as this indicates poor control (NAEEP, 2007).

Avoid or reduce exposure to allergens; this will reduce symptoms and risk for acute asthma attacks (McCracken, et al., 2017).

Return to clinic or seek immediate care when symptoms are not managed with current regimen (NAEEP, 2007).

Self-monitoring: Peak flow meter monitoring: Home peak flow monitoring can be used to monitor for worsening of asthma and the need for an office visit (McCracken, et al. 2017). Peak flow monitoring is beneficial by detecting early changes that require treatment and by evaluating responses to changes in therapy (NAEEP, 2007). Patients need instructions, demonstrations, and frequent reviews to ensure appropriate technique when using a peak flow meter at home (NAEEP, 2007). Michelle must be willing to incorporate the use of the peak flow meter in her plan of care and she should be taught that if she will periodically use the peak flow meter throughout the day, at home and at work, monitoring may be useful when evaluating responses to changes in treatment, environmental or occupational exposures and bronchospasm (NAEEP, 2007).

Annual Flu shot: it is recommended that individuals with asthma receive a flu shot because influenza affects the respiratory system and increase the risk of asthma attacks (CDC, 2018).

Hypertension education: Teach definition and risk associated with hypertension, as well as teach lifestyle modifications include diet, exercise, blood pressure monitoring at home (Whelton ; Carey, 2018).Additional Diagnostic Testing: Allergy testing referral: A referral is recommended to establish the target allergen causing asthma and testing requires adequate training to perform and interpret (Price, Bjermer, Bergin, ; Martinez, 2017). No other laboratory or diagnostic testing is necessary at this time to establish a diagnosis of asthma. The diagnosis and severity are determined by history, physical examination, spirometry, allergen sensitivity, and evidence of reversible obstruction or airway hyperresponsiveness (McCracken et al., 2017).
Activity: As tolerated, educated on signs and symptoms exercise-induced asthma and how to manage if it occurs.

The goals of asthma treatment are aimed at reducing symptoms, maintaining normal activities, achieving (nearly) normal pulmonary function test values and reduce risks associated such as future exacerbations, medication adverse effects (McCracken, et al., 2017). Therefore, normal activity is encouraged; a follow up visit is necessary if activities of daily living cannot be completed per the normal (McCracken, et al., 2017).

Follow up: 1 week to recheck blood pressure; I would repeat blood pressure to establish a diagnosis of hypertension with 2 blood pressure readings and 2 separate occasions (Whelton ; Carey, 2018).

Asthma: 2 weeks: It is recommended in the guidelines to follow up within 2 to 4 weeks (NAEEP, 2007). I will request a 2 week follow to discuss the alleviation or worsening of symptoms, how M.G. feels about her medication regimen, and to review medications, inhaler technique, peak flow monitoring, and asthma action plan (McCracken, et al., 2017).
Referrals: Only for Allergy testing: A referral is recommended to establish the target allergen causing asthma and testing requires adequate training to perform and interpret (Price, Bjermer, Bergin, ; Martinez, 2017). M.G. previously received allergy shots that were effective.
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