Subjective Data
Chief Complaint: severe wheezing, shortness of breath, intermittent coughing, unable to talk without having to catch her breath.
History of Present Illness: The current illness is a combination of older illnesses and injuries caused by a recent motor vehicle accident. The patient has had asthma attacks regularly for over 40 years. The attacks have become frequent in the last two months, manifesting up to 4 attacks per week. Current treatment includes a combination of Theophylline SR Capsules and Albuterol inhaler, PRN. Secondly, the patient also had a diagnosis of congestive heart failure three years ago. To manage this, the patient is on Enalapril 5 mg PO BID and Oral Hydrochlorothiazide 50 mg and a restrictive sodium diet. The CHF has been under control for a year. Finally, the patient was recently involved in an accident, which resulted in sporadic seizures. The patient is currently on Phenytoin SR capsules 300 mg PO QHS to control the seizures.
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PMH/Medical/Surgical History:
Surgical history: None
Psychiatric history: None
Injuries: Recent head injury
Hospitalizations: Lastly ten-week ago
Obstetric History: None
Known Allergies: None
Present medication includes:
1. Theophylline SR Capsules 300 mg PO BID and Albuterol inhaler, PRN for asthma
2. Phenytoin SR capsules 300 mg PO QHS to control seizures
3. HTCZ 50 mg PO BID and Enalapril 5 mg PO BID to manage congestive heart failure.
Significant Family History:
Father died at 59 due to hypertension-related kidney failure. The mother died at 62 due to congestive heart failure. Therefore, the patient has inherited risk for both hypertension and CHF
Social History:
The patient does not smoke or take alcohol but takes high levels of nicotine daily.
Review of Symptoms:
General: Positive of anxiety. Denies feeling depressed.
Integumentary: Positive for paleness. Denies any discomfort on the skin.
Head: Normal
Eyes: Normal
ENT: Normal
Cardiovascular: Positive for stage 2 hypertension. Denies feeling dizzy.
Respiratory: Positive for Bilateral expiratory wheezes. Denies chest pains
Gastrointestinal: Normal
Genitourinary: Normal
Musculoskeletal: Normal
Neurological: Normal (Alert and Oriented)
Endocrine: Normal
Hematologic: Normal
Psychologic: Normal
Objective Data
Objective Data:
Vital Signs: BP - 171/94; P 122; R 31; T 96.7 F; Wt. 145; Ht. 5’ 3”; BMI. 25.69
Physical Assessment Findings:
HEENT: Normal
Lymph Nodes: Normal
Carotids: Normal
Lungs: Bilateral expiratory wheezes
Heart: Normal
Abdomen: Normal
Genital/Pelvic: Normal
Rectum: Normal
Extremities/Pulses: Normal
Neurologic: Normal (A&O X3)
Laboratory and Diagnostic Test Results:
Na – 134 mEq/L: reflective of mild hyponatremia
K - 4.9: Reflects a normal White blood cell (WBC) count.
Cl - 100MEq/L: Slightly elevated but not to the threshold of kidney failure symptoms.
BUN – 21 mg/dL. Normal but slightly elevated.
Cr - 1.2 mg/dL: Slightly elevated but relatively normal for a 65- year old woman.
Glu – 110126 mg/dl: Slightly elevated but below the threshold for diabetes.
ALT – 24 units per liter: Within the range of normal Alanine aminotransferase.
AST – 27 units per liter: Within normal range for aspartate aminotransferase
Total Chol – 190 mg/dL: Extremely high cholesterol levels.
CBC – WNL: Normal complete blood count
Theophylline - 6.2 mcg/mL: Within normal levels
Phenytoin – 17 µg/mL: Within the normal range, thus a low risk for seizures.
Assessment
Diagnosis 1: ICD 10 code I501: Cardiac asthma
The diagnosis with the highest priority for its potential negative implications of ICD code I501, the ICD-10 classification for Cardiac Asthma. By definition, cardiac asthma is when asthma happens superficially as a manifestation of congestive heart failure (Keet & McCormack, 2016). Based on the totality of symptoms as outlined above, cardiac asthma is not the most probable diagnosis. However, cardiac asthma takes priority herein as it could have the most adverse consequences for the patient and also need urgent intervention. The basis for this diagnosis is a combination of active symptoms and patient history. Active symptom includes wheezing, coughing, and extreme shortness of breath to the point of inability to speak coherently (Keet & McCormack, 2016). Further, the fact that the use of an Albuterol nebulizer significantly lowered the patient’s blood pressure may also point to cardiac asthma as the main problem. Historical factors include the fact that the patient’s mother died due to CHF and that the patient already had a CHF diagnosis.
Second Diagnosis: ICD-10-CM Code J45: Asthma Attack
The second diagnosis, and also the most probable diagnosis, is ICD-10-CM Code J45: Asthma Attack. This diagnosis stems from the active signs and symptoms of the patient and the fact that the patient has a 40-year history of asthma. The signs include wheezing and shortness of breath (Yawn & Han, 2017). Further, the patient’s hypertension may have resulted from anxiety due to breathing problems. This hypothesis can explain the substantial reduction in the patient’s blood pressure after the administration of an Albuterol nebulizer.
Third Diagnosis: ICD-10-CM Diagnosis Code N28.9: Kidney Disease
The patient could also be having an early onset of kidney disease, based on current symptoms and patient history. First, the patient’s father died at the age of 59, which the patient had already passed due to kidney disease. Secondly, the patient had an accident that resulted in serious injury ten weeks ago. The events associated with the accident can exacerbate a kidney problem. Finally, whereas the blood tests do not reach the threshold for kidney disease yet each of them, including blood urea nitrogen (BUN) and mild hyponatremia, could also point to a problem with the kidneys. Finally, the fact that the patient has an exponentially high level of cholesterol and also consumes high levels of caffeine could contribute to kidney disease (Kovesdy, Furth & Zoccali, 2017).
Plan of Care
Diagnosis 1: Cardiac Asthma
The patient needs immediate admission for specialized care. The two most agent problems are the inability to breathe for which Albuterol nebulizer has been effective. Continued administration of Albuterol nebulizer is necessary. Further, the patient will need Altoprev (extended-release): 10-60 mg PO for the management of high cholesterol. Regarding patient education, she will need guidance on healthy eating to lower both her weight and her cholesterol levels.
Diagnosis 2: Asthma
The patient needs immediate admission for specialized care since her current signs signify an asthma emergency. She will also need Albuterol nebulizer to manage her asthma attack and continue taking Theophylline SR Capsules 300 mg PO BID. The fact that her condition reacted positively to Albuterol creates the possibility that she has not been using it effectively, hence her medical emergency. The patient will thus need patient education regarding effective and regular use of prescribed medication.
Diagnosis 3: Kidney Disease
The patient will also need admission for further tests to either confirm or rule out kidney disease. For a start, the patient needs Altoprev (extended-release): 10-60 mg PO to reduce her cholesterol. Patient education is also necessary to enable the patient to reduce her caffeine intake, both in terms of coffee and diet colas. Finally, the patient will need a review of other medications to ensure that they are not contributing to kidney disease.
References
Keet, C. A., & McCormack, M. (2016). Cardiac asthma: An old term that may have new meaning? The Journal of Allergy and Clinical Immunology: In Practice , 4 (5), 924-925.
Kovesdy, C. P., Furth, S. L., & Zoccali, C., (2017). Obesity and kidney disease: hidden consequences of the epidemic. American Journal of Hypertension . 30 (3). 328–336,
Yawn, B. P., & Han, M. K. (2017, November). Practical considerations for the diagnosis and management of asthma in older adults. In Mayo Clinic Proceedings 92, (11), 1697-1705. Elsevier.
