medical report for asthmatic patient

Primary Diagnosis: Asthma The case study patient for this paper presented with episodic shortness of breath, and chest tightness. A physical examination conducted on the patient indicates headaches, throat inflammation, hoarseness, panic, depression, wheezes, breathing difficulty, and lung congestion.

Full Answer

How to assess a patient with asthma in a hospital?

Assessment of a patient with asthma includes the following: 1 Assess the patient’s respiratory status by monitoring the severity of the symptoms. 2 Assess for breath sounds. 3 Assess the patient’s peak flow. 4 Assess the level of oxygen saturation through the pulse oximeter. 5 Monitor the patient’s vital signs.

What are the criteria for the diagnosis of severe asthma?

This is recommended for patients who meet one or more of the following criteria: have moderate or severe persistent asthma, have poor perception of changes in airflow or worsening symptoms, have unexplained response to environmental or occupational exposures, or at the discretion of the clinician or patient. Function.

What are supportive measures for the treatment of asthma?

Supportive measures include seeking medicalattention, avoiding Asthma triggers, taking medication, and check peak flow meter for a measure of infection.

Which data collection methods are used in the workup of asthma?

Virtual data collection methods (i.e., telephone and online platforms) were used to conduct 10 online focus groups with asthma patients and caregivers, and 11 in-depth interviews with clinicians who treat patients with asthma. Analysis used a notes- and transcript-based process.

What is the medical diagnosis for asthma?

Spirometry. This is the main test doctors generally use to diagnose asthma in people 5 years or older. To help determine how well your lungs are working (pulmonary function), you take a deep breath and forcefully breathe out (exhale) into a tube connected to a spirometer.

What should an asthma patient monitor?

There are four key symptoms that you should monitor to help you keep your asthma under control:Daytime Symptoms. How often do you have asthma symptoms during the day, such as coughing, wheezing, chest tightness or shortness of breath?Nighttime Symptoms. ... Quick-Relief or Rescue Inhaler Use. ... Activity Level.

Why is medical history important for asthma?

This also includes all previous medical conditions. A history of allergies or eczema increases your chance of asthma. A family history of asthma, allergies or eczema increases your chance of having asthma, too. Tell your doctor about any home or work exposure to environmental factors that can worsen asthma.

What are the physical examination of asthma?

During a physical exam for asthma or allergies, your doctor will look at your ears, nose, throat, eyes, skin, chest and lungs. They may: Listen to your lungs for wheezing or whistling that could mean inflammation. Look in your nose and throat for swelling and drainage that could be caused by allergies.

What are the 4 categories of asthma?

Ideally, asthma severity is determined before initiating therapy. The EPR-3 guideline classification divides asthma severity into four groups: intermittent, persistent-mild, persistent-moderate, and persistent-severe.

What questions should I ask a patient with asthma?

Seven questions to ask your patients about asthmaDo you understand what asthma is? ... Do you know what triggers your asthma? ... Do you know when to come to the ED? ... Do you understand the difference between your medications? ... Will you seek follow-up care? ... Do you know how to use your inhaler? ... Do you monitor symptoms at home?

Can CBC detect asthma?

A simple calculation using routine blood test results can identify eosinophilic asthma patients. Complete blood count (CBC) with differential, a standard test that enumerates different types of white cells in peripheral blood, is often performed during routine patient visits in clinics and hospitals.

How do you get asthma history?

A history should explore typical symptoms of asthma: wheeze, cough and breathlessness. It should also include triggers, exacerbations, treatment adherence and a systems review. Clinical examination may be normal or may show signs of hypoxia and polyphonic expiratory wheeze.

What are the 3 types of asthma?

Types of asthmaDifficult to control asthma.Severe asthma.Occupational asthma.

What is the presentation of asthma?

Typical symptoms include cough, wheezing, shortness of breath, and chest pain or tightness. Some individuals also may report sore throat or GI upset. Initially, airway dilation is noted during exercise.

Can chest xray show asthma?

Generally, doctors do not use chest X-rays to diagnose asthma. Instead, they may use this test to rule out conditions other than asthma. Other conditions may cause similar symptoms to asthma. For example, an individual may have something stuck in their airways.

What are nursing interventions for asthma?

Nursing Care Plan for Asthma 1Nursing Interventions for AsthmaRationalesAdminister the prescribed asthma medications (e.g. bronchodilators, steroids, or combination inhalers / nebulizers).Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs.4 more rows

What assessment information would indicate the patient's asthma is worsening?

A drop in peak flow meter readings. Chronically lower peak flow meter readings can indicate that your asthma is getting worse.

What is the management of asthma?

The four parts of managing asthma are: Identify and minimize contact with asthma triggers. Understand and take medications as prescribed. Monitor asthma to recognize signs when it is getting worse.

Why is it important to monitor the oxygen saturation of a person with severe asthma?

During an asthma exacerbation, or asthma attack, a person may have lower blood oxygen levels, as asthma can reduce the body's capacity to take in oxygen. By measuring their blood oxygen levels, a person can get an idea of how well their body distributes oxygen from the lungs to their cells.

4. Marketing Objective

To establish Asthmaest as an agent of choice to ensure the easiest way of use among all category of patients as normal, serious, Children, young & elderly.

7. Promotional Strategy and Platform

1. Develop awareness regarding the use of a Powder based medicine in serious moments:

8. Sales Force

A dedicated team of 10 persons is required to promote Asthmaest in 2006 to selected doctors. If we employ a dedicated team they will be able to make 4 calls per day since a huge portion of their time will be spent in travelling and waiting for opinion leaders and high prescribers.

How old was S.A. when she had pneumonia?

S.A. had pneumonia when she was 24. As a young child, she often had a cold and a sore throat, which led to bronchitis. She also had influenza four times (at the age of 15, 18, 19, and 23). The patient claims to have never experienced any difficulties breathing before, though. Get your.

Why are the airways narrowing in a patient?

According to the physical assessment results, the patient’s airways narrow as a result of being exposed to certain factors such as the presence of pollen in the air.

What are some examples of allergies?

Allergies. The patient is allergic to pollen, dust, cold air, smoke, fumes, animals, and mold. Furthermore, the instances of allergy can be caused by strong scents, in general. For example, S. A. stated that she had a breathing problem after scenting strong perfume.

Why is HCM so reluctant to use medical services?

rarely uses healthcare services, mostly because her work occupies a significant amount of her time. Furthermore, the patient is reluctant to use medical services because of the fear of experiencing significant pain in the process.

Is hair healthy for asthma?

S. A.’s hair can be defined as relatively healthy, although it is not thick and is prone to falling out. The observed phenomenon can be attributed to the increase in the stressful experiences associated with asthma, as well as improper dieting (particularly, the lack of protein) (Grond, 2017).

Does family history include allergies?

Specifically, there has been no known history of allergies or asthma.

Is S. A.'s mental health impaired?

Thus, the patient’s mental health status can be regarded as positive. S. A.’s mental health is not impaired. She can thin coherently and properly. However, the presence of anxiety needs to be addressed (Bruzzese et al., 2016).

What are the symptoms of asthma?

Most common symptoms of asthma are cough (with or without mucus production), dyspnea, and wheezing (first on expiration, then possibly during inspiration as well). Cough.

Why do asthma patients need to undergo tests?

Patients with recurrent asthma should undergo tests to identify the substances that precipitate the symptoms.

What is Asthma?

Asthma affects people in their different stages in life, yet it can be avoided and treated.

What is the pathophysiology of asthma?

The underlying pathophysiology in asthma is reversible and diffuse airway inflammation that leads to airway narrowing.

How long does asthma last?

Patients with asthma may experience symptom-free periods alternating with acute exacerbations that last from minutes to hours or days. Asthma, the most common chronic disease of childhood, can begin at any age.

What is the best medication for asthma?

Short-acting beta2 –adrenergic agonists. These are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. Anticholinergics. Anticholinergics inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of the airway.

What are the symptoms of exercise induced asthma?

Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal symptoms, and sometimes only a description of a “choking” sensation during exercise. A severe, continuous reaction, status asthmaticus, may occur.

What are the symptoms of asthma?

In addition to that, the patient also experiences chest pains, heavy coughs, anxiety, dizziness, and lightheadedness. The huge tonsils, high wheeze pitches, heavy breaths, chest pains, and chest tightness strongly suggest Asthma diagnosis. Moreover, the lung congestion and chest retraction causing cracking and snoring indicate strong breathing difficulties (“Asthma – Diagnosis and treatment – Mayo Clinic,” 2018). The skin rash, itching, pumps, redness, swelling, elevation, and nose sneezing with blocked sinuses are the cause of asthma symptoms becoming worse. The rate of allergies is high hence the patient’s illness patterns that of fatal Asthma. This is strengthened by previous diagnosis f individuals presented with similar Asthma symptoms.

How to manage asthma?

Short-term medication is used to alleviate symptoms. People with recurring symptoms tend to take long-term routine treatment to manage the underlying inflammation and to avoid complications and exacerbations. It is also necessary to prevent causes of asthma-symptoms that irritate and inflame the airways (Fergeson et al., 2016). Any asthma patient will know with professional assistance what causes he or she can avoid. Long-term medication is used to manage symptoms and preventing extreme effects such as panic attacks and depression usually involving therapy. Preventive, long-term monitoring medications reduce the inflammation that contributes to the discomfort of the airways. Quick-relief inhalers (bronchodilators) quickly open up swollen airways which obstruct breathing. Allergy drugs are required in some situations.

What is a spirometry test for asthma?

It is the most recommended laboratory test for Asthma patients both adults and childrenIt measures the highest amount of air the patient lungs can exhale. The patient is advised to take as big a breath as necessary, close his or her lips around the spirometer’s mouthpiece and blast out the air as rapidly and as thoroughly as possible. This has to be done with all possible effort and reproducibility. The valueobtained is below 0.70, then there is airway obstruction. If the result is above 0.70 then the patient does not have airway obstruction hence normal lungs (“Asthma in adults differential diagnosis – Epocrates online,” 2020). The test is, therefore, requiring to confirm the reversibility of the airway, which is Asthma. The Spirometry diagnosis test is carried out to determines the period patient is put into a recovery therapy program.

How many people have asthma?

Without it, you may continue to visit the emergency department regularly, and even longer at the facility, which may impact your home life and job capacity.An individual can be impaired by asthma at any level, but it is more severe in people under 40. This is owned by over 20 million individual Americans, about 8.3 percent of the adult population. If you have a family history of asthma and allergies you are more likely to get it (“Asthma – Diagnosis, and treatment – Mayo Clinic,” 2018). On the other hand, long-term asthma attacks (status asthmaticus) do not respond to bronchodilator treatment, and are a medical emergency. In boy’s asthma happens more often than in girls. It’s unclear why that is, but certain researchers consider that the airway capacity of a young male is narrower relative to the airway of the girl, which may lead to an elevated chance of wheezing during a cold or other viral infection. The asthma ratio between men and women is the same by age 20. Around 40, more females have adult asthma than males. Three fifths in the asthma cases are believed to be inherited. When a person has an asthma parent, then he or she is three to six times more likely to have asthma than someone who has no asthma parent. Several results indicate that children with atopic dermatitis can suffer more serious and chronic adult asthma.

What is the best medication for asthma?

Inhaled medication that open airways include salmeterol (Serevent) and formoterol (Foradil, Perforomist).

What causes asthma?

Allergy-induced asthma, caused by airborne contaminants such as pollen, mold spores, cockroach or skin debris, and pet-shredded, dried saliva. Several studies indicate a correlation between cigarette smoking and an increased risk of developing asthma.

Is hyperventilation a form of asthma?

Hyperventilative syndrome and panic attacks are Asthma effects on the patient. The disease portrays respiratory symptoms similar to Asthma patients. Patients with hyperventilation syndrome and panic attacks present shortness of breath, lightheadedness, chest pain sensation, dizziness, and extreme tingling sensation. However, the features that distinguish this diagnosis from Asthma are faintness and palpitation (“Asthma in adults differential diagnosis – Epocrates online,” 2020). The disease is considered considering features such as depression and anxiety presented by Asthma patients that may be as a result of panic attacks.

What is the step 3 of asthma management?

In the step 3 of asthma management, an add-on therapy, LABA is given and the control of asthma is monitored . In this case, the patient was given OXIS inhaler which is formoterol 9mcg once daily.

How many people die from asthma in the world?

Asthma affects people of all ages, but it normally starts at childhood1. Asthma affects 5-8% of the population around the world2. A study done by World Health Organization (WHO) shows that there are 15 million disability-adjusted life years lost yearly because of asthma, displaying 1% of total disease burden worldwide3. The annual worldwide mortality caused by asthma is estimated to be 250,000. In Scotland, the incidence of clinical asthma is around 18.4% of the population3.

How many puffs of salbutamol are given for asthma?

According to the SIGN guideline of acute asthma management, inhaled short acting β2 agonist is given by 4-10 puffs of 100mcg salbutamol or nebulised salbutamol 5mg while ipratropium bromide 500mcg is given via oxygen driven nebulizer. In this case, the patient was given nebulizer AVN 2:1:2 where the atrovent (ipratropium) is 2 units with a total of 500mcg while ventolin (salbutamol) is 1 unit which is 5mg. This complies with the guideline.

How much steroid should I take for asthma?

As mentioned in the SIGN guideline for asthma control, step 2 was to add an inhaled steroid of 200-800mcg daily . 400mcg of steroid per day as starting dose is suitable for most patients. In this case, the patient was prescribed MDI budesonide 400mcg two times daily thus the therapy complies with the guideline.

Can corticosteroids be used for asthma?

Another study was done on 53 patients to compare the use of 2 different corticosteroids administration route used for acute asthma treatment which is the oral and intravenous route. It is found that there is no significant difference in the two groups of patients and both demonstrates same results11. This showed that oral corticosteroids can be used in this case.

Can Budesonide be used for asthma?

There was also lesser risk of acute exacerbation of asthma in budesonide group17. Hence, budesonide can be used to as asthma control in asthmatic patients as shown in this case.

How does insurance affect asthma?

Insurance coverage affected caregivers’ , patients’, and health care providers’ decisions about treatment. Most patients and caregivers would forego uncovered treatment, though caregivers were more willing than patients to pay for uncovered medications. Other factors that may affect decision-making about asthma treatment include safety, side effects, benefits, success rates, and asthma severity . A few adult patients were concerned about developing a drug dependency or addiction (especially to pills). Patients with comorbidities also were concerned about drug interactions and contraindications, especially for oral medications.

What are the best websites for asthma?

Preferred sources for asthma information included websites such as UpToDate, AAP SmartBrief, NHLBI, WebMD, and Mayo Clinic, or apps such as Lexicomp, AAP, PDR, and Medscape.

What are some asthma treatment strategies?

Patients and caregivers also discussed other asthma treatment and management strategies, including allergy shots, reducing home allergens, and—for adult patients only—bronchial thermoplasty. (Biologics were not discussed).

How many focus groups were conducted with groups who traditionally have high rates of asthma?

Ten focus groups were conducted with groups who traditionally have high rates of asthma, including English- and Spanish-speaking lower- to lower-middle income adult patients and caregivers. There were few differences in the perspectives of adults with asthma versus caregivers and English versus Spanish speakers.

Why is symptom relief important?

symptom relief so that patients can be more physically active.

Can you use the same inhaler for asthma?

Patients and caregivers generally were receptive to using the same inhaler to both treat asthma and prevent exacerbations. However, some questioned whether one inhaler could do both effectively.

What is a Patient Medical Report?

A patient medical report is a comprehensive document that contains the medical history and the details of a patient when they are in the hospital. It can also be given as a person consults a doctor or a health care provider. It is a proof of the treatment that a patient gets and of the condition that the patient has. It has the complete diagnosis on the patient, clearly stating the disease that should be treated. Through a patient medical report, anyone can analyze the health condition of a person. It sometimes contain a patient chart where the demographic profile of the patient is introduced. All types of medical records need a medical report. Patient medical records are simple data about the patient while a patient medical report is more elaborate and comprehensive. Though the importance of medical records and the purpose of medical records are almost the same with a patient medical report, the patient medical report is more beneficial. It has a complete summary of the diagnosis on the patient and have some recommendations for the health of the patient.

What should be documented in a patient's medical report?

One thing that a doctor should have documented in the patient medical report is the medical diagnosis that he has found in the patient. Whatever disease that a patient has should be clearly stated in the medical report. The name of the disease should be clearly written and some explanations about the current condition of the patient.

Why should a patient's medical report include lab results?

It is also needed because sometimes the laboratory and the test results are the proof of the sickness of the patient. For example, if the patient has a blood cancer, it can be seen with the blood tests. If the patient has a brain tumor, it can be seen through a brain CT scan. A CT scan for the body can also tell whether we have a fracture or not.

Why should medication be documented in a medical report?

The treatments or medications should also be documented because it can provide a good information about the medical history of a patient. Put the names of the medicines and tell how often did the patient takes it. You can also document its effect and tell whether it is effective for them.

Is a medical report a legal document?

If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patient is under your care. Thus, it can be used in court as an essential proof. So, keep a patient medical report because you may need it in the future.

Do health care providers have access to patient medical records?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patients’ access to the patient medical report is a must. It is their right to see their medical report. It is against the law not to show them their medical report. It can be a proof if there is any doctor withholding treatments. So, to avoid conflict, the patient medical report should be shown to the patients. HIPAA (Health Insurance Portability and Accountability Act) has been passed in the Congress of United States. Passed in 1996, it specifies who can have an access to all the health information. You can research for that law, so you can have the exact details to who can have an access to a patient medical report. It is better because you can have a legal source. It can tell you all the things that you need to know about it.

What are the symptoms of a rib infection?

Indications: Diseases of the chest and ribs--cardiac pain, palpitations, vomiting, acid reflux, plumpit qi ( the sensation of a foreign object in the throat); stomach pain; mania and depression; pain and weakness of the elbow and arm; malarial disease; red face and eyes; palpable abdominal masses; wind strike--epilepsy.

What are the emotional factors that affect the lung meridian?

Energetic disturbances in the lung meridian may involve one or more of the following emotional factors: ability to take in life, depression, grief, sadness, yearning, anguish, not feeling worthy of living life fully, desperation, cloudy thinking.

What Is Asthma?

• General statement
  To establish Asthmaest as an agent of choice to ensure the easiest way of use among all category of patients as normal, serious, Children, young & elderly. Key issues 1. Little understanding of our rural doctors & patients regarding coagulation cascade and related produc…
• Proposition:
  Asthmaest has following distinct features and benefits which make it completely different and preferred choice of agent by community than other available products: a) Improvement over the proportionate of drug b) Rapidly using system c) No more use of spacer, musk, nebulaelizer or in…

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Pathophysiology

Statistics and Epidemiology

Causes

Clinical Manifestations

• Vital Signs
  Pulse 87, temperature 105°F, blood pressure 119/75, weight 107, height 5’2”, respiration 23, and body mass index (BMI) 19.6.
• Mental Status Exam
  S. A. is properly groomed, her clothes being neat, and her hair is arranged in a simple yet neat way. S. A. articulates her ideas well and is fully aware of her environment and condition, which can be viewed as the sign of her having no mental issues. Similarly, no behavior disorders have been sp…

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Prevention

Complications

Assessment and Diagnostic Findings

Medical Management

Practice Quiz: Asthma