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Case Study : Asthma

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Case Study : Asthma
Asthma Jennifer Martinez

Asthma Case Study Mr. Vargas, a 45-year-old male patient is rushed in to the emergency room by his wife. The patient is short of breath and gasping for air has dyspnea and audible wheezing on expiration. Mr. Vargas stated to the nurse that he noted his difficulty in breathing while going up a flight of stairs in his building. The patient complained of an “annoying and nagging cough” with persistent chest tightness. The patient also stated that everytime he coughed, a thick, white mucous came out. He described it as “white, gooey, stinky gunk”.
Past Medical History: Patient was admitted through the ER of another hospital several years ago due to an episode of bronchitis. Patient states his symptoms back then were very similar to the ones he has presently, such as the wheezing, chest pain and diaphoresis.
Allergies: Penicillin
Medications: Bayer aspirin 81mg once a day Glucosamine and Chondroitin 1500 mg once a day
Family History: Father passed away from a community acquired pneumonia three years ago at the age of 70.Mother died at 68 of natural causes.
Social History: The patient is married and lives with his three sons and wife in the suburbs. Patient has been an asbestos handler for almost twenty years. On his free time he enjoys bike riding with his sons. Patient has been a one pack a day smoker for the past twenty years, with limited alcohol use.
Review of Systems: Intermittent chest pain, shortness of breath, wheezing and diaphoresis.
Physical Examination: Patient was alert and oriented to time, date and place. His vitals were taken and recorded. His blood pressure 144/88mm Hg, pulse 102 beats per minute, had an oral temperature of 100.2 degrees Fahrenheit, respiratory rate of 26 and an oxygen saturation level of 90% on room air. Patient was noted sitting in upright position, with excessive use of his accessory muscles of respiration. It was noted that he had diminished breath



References: Boulet, L. (2011). Asthma control, education, and the role of the respiratory therapist. Canadian Journal of Respiratory Therapy, 47(4), 15-21. Casey, G. (2012). Asthma- obstructing the airflow. Kai Tiaki Nursing New Zealand, 18(9), 20-24. Craven, R.F., & Hirnle, C.J. (2009). Fundamentals of nursing: Human health and function. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Greener, M. (2010). Improving outcomes among adults with asthma. Nurse Prescribing, 8 (6), 270-273. Holmes, L. (2012). Definitions, diagnosis and phenotypical treatment of severe asthma. Primary Health Care, 22(8), 32-38. Kaufman, G. (2012). Asthma update: recommendations for diagnosis, treatment and management. Primary Health Care, 22(5), 32-39. McCarty, K., & Rogers, J. (2012). Inpatient asthma education program. Pediatric Nursing, 38(5), 257-263. O’laughlen, M. C., & Rance, K. (2012).Update on asthma management in primary care. Nurse Practitioner, 37(11), 32-40.

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