History of Present Illness (HPI) Case Study: Status Asthmaticus

Introduction

A 30-year-old Caucasian male who is a known asthmatic patient, presents to the emergency department with complaints of shortness of breath that has lasted for 6 hours. He reports that it was gradual in onset and started immediately while visiting a relative and spending time in the garden. The shortness of breath was not exacerbated by exercise or effort and has no diurnal variation (Walker and Colledge, 2013). The patient reports shortness of breath even at rest. The patient reports to have taken several puffs of his inhaler, but the shortness of breath did not stop. There was no associated chest pain however patient reports a dry cough. He denies having any fever or sweating. He denies having any palpitations, Paroxysmal Nocturnal Dyspnea (PND), orthopnea, ankle swelling or calf tenderness.

Past History

The patient is a known asthmatic patient since ten years of age. He has been on Salbutamol that he uses p.r.n.

He was once hospitalized at 25 years of age due to pneumoniae. He was treated and discharged on medications that he cannot remember.

Aside from asthma, the patient has no other chronic condition or comorbidities

There is no history of surgeries or blood transfusions

Denies accidents or injuries.

Denies past or present psychiatric illness.

No known drug or food allergy

Social History

The patient is a known smoker- 0.5 pack years.

He reports being a social drinker. He drinks beer occasionally with his friends, and he cannot quantify the amount.

Denies use of any illicit drugs

Family History

He is married to one wife, and together they have two children.

The wife and children are well, with no known medical condition.

They live in an apartment.

He is an electrical engineer by profession and works in Philips Company

He holds a bachelor's degree in electrical engineering from Yale.

Both parents are alive.

Patient reports a maternal familial history of asthma. The mother is asthmatic and on corticosteroids and salbutamol inhaler.

He reports that both his father and grandfather have diabetes.

His has three siblings, and his elder sister is also asthmatic.

The other two siblings are well with no known medical condition.

Systemic Review

General: Denies fever, chills, body aches, night sweats or weight loss

Skin: Unremarkable

Head: Unremarkable

Gastrointestinal: Unremarkable

GUS: Unremarkable

MUS: Unremarkable

Neurologic: Unremarkable

Psychiatric: No history of psychiatric illness.

Objective (O) Data.

General Examination

This is a 30-year-old patient, who is lying in bed and severe respiratory distress as evidenced by flaring of the alar nase and use of accessory muscles of respiration. He is on nasal prongs delivering oxygen at a rate of 10litres per minute.

He is not jaundiced, there is no pedal oedema, no anaemia, no cyanosis, no lymphadenopathy, he appears to be of good nutritional status, and he is not dehydrated. However, there is finger clubbing grade 3.

Vital Signs

Temperature 36.0 oC; Pulse: 120; Respiratory Rate: 36 breaths per minute; Blood pressure; 120/75; Oxygen saturation on room air: 78; Oxygen saturation on oxygen: 87

Systemic Examination

Respiratory Examination: On inspection: The chest appears barrel-shaped, however, there are no obvious surgical or therapeutic scars, the chest is moving with respiration, there is the use of accessory muscles of respiration such as the intercostals and sternocleidomastoid. On palpation: there was no palpable mass or tenderness. There was symmetrical chest expansion. The chest was resonant on percussion. On auscultation: Vesicular breath sounds heard but no good air entry bilaterally. There were added breath sounds such as wheeze heard all over the lung cavity and crackles on the bases of the lungs.

Cardiovascular (CVS) examination: S1 and S2 heard. No added heart sounds.

Abdominal examination: The abdomen is not distended. Bowel sounds heard and no localized abdominal tenderness.

Central Nervous System (CNS) examination: Patient is conscious with a GCS score of 15/15. He is well oriented to time, place and person. Cranial nerves are intact. The cerebellar and sensory function is intact. Muscles groups tested, and all appear to be of normal tone, power and bulk.

Musculoskeletal (MUS) examination: Patient can ambulate and reports no pain.

Assessment (A)

Working diagnosis: Status asthmaticus.

Differential diagnosis:

Pneumonia

Pulmonary embolism

Bronchitis

Plan (P)

Diagnostic:

Spirometry check at how the lungs are functioning

Peak Expiratory Flow (PEF) check how the lungs are functioning

Full Haemogram to detect presence of bacteremia.

Chest X-Ray and CT scan have been shown to be helpful in diagnosing acute exacerbations of asthma (Ash and Diaz, 2017).

Medication management:

The patient will be nebulized by salbutamol such as salbutamol (Castillo et al., 2017).

Referral: I will refer to a chest physician after stabilizing the patient.

Patient and family education (including follow-up)

I informed the patient that he has a status asthmaticus- an asthmatic attack that lasts for more than 30 minutes.

I told him that his visit to the garden could have been the cause of the attack. He must have responded to an allergen -such as pollen grain- encountered in the garden.

I explained to the patient the importance of spirometry and PEF.

I told the patient that he would have to be treated as an in-patient. He will be nebulized by higher doses of bronchodilators to stop the shortness of breath.

References

Ash, S. Y., & Diaz, A. A. (2017). The role of imaging in the assessment of severe asthma. Current opinion in pulmonary medicine, 23(1), 97.

Castillo, J. R., Peters, S. P., & Busse, W. W. (2017). Asthma exacerbations: pathogenesis, prevention, and treatment. The Journal of Allergy and Clinical Immunology: In Practice, 5(4), 918-927.

Walker, B. R., & Colledge, N. R. (2013). Davidson's Principles and Practice of Medicine E-Book. Elsevier Health Sciences.