65 year old Caucasian female that was discharged from the hospital 10 weeks ago
ID: 87090 • Letter: 6
Question
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.
Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment - BP 134/79, HR 80, RR 18
Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.
Na - 134
K - 4.9
Cl - 100
BUN - 21
Cr - 1.2
Glu – 110
ALT – 24
AST - 27
Total Chol – 190
CBC - WNL
Theophylline - 6.2
Phenytoin - 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).
Explanation / Answer
The three priority diagnosis are:
1st Priority: Asthma Diagnosis:
Overview:
Asthma is a chronic disease involving the airways in the lungs. These airways, or bronchial tubes, allow air to come in and out of the lungs.
If you have asthma your airways are always inflamed. They become even more swollen and the muscles around the airways can tighten when something triggers your symptoms. This makes it difficult for air to move in and out of the lungs, causing symptoms such as coughing, wheezing, shortness of breath and/or chest tightness.
For many asthma sufferers, timing of these symptoms is closely related to physical activity. And, some otherwise healthy people can develop asthma symptoms only when exercising. This is called exercise-induced bronchoconstriction (EIB), or exercise-induced asthma (EIA). Staying active is an important way to stay healthy, so asthma shouldn't keep you on the sidelines. Your physician can develop a management plan to keep your symptoms under control before, during and after physical activity.
People with a family history of allergies or asthma are more prone to developing asthma. Many people with asthma also have allergies. This is called allergic asthma.
Occupational asthma is caused by inhaling fumes, gases, dust or other potentially harmful substances while on the job.
Childhood asthma impacts millions of children and their families. In fact, the majority of children who develop asthma do so before the age of five.
There is no cure for asthma, but once it is properly diagnosed and a treatment plan is in place you will be able to manage your condition, and your quality of life will improve.
An allergist / immunologist is the best qualified physician in diagnosing and treating asthma. With the help of your allergist, you can take control of your condition and participate in normal activities.
Symptoms:
According to the leading experts in asthma, the symptoms of asthma and best treatment for you or your child may be quite different than for someone else with asthma.
The most common symptom is wheezing. This is a scratchy or whistling sound when you breathe. Other symptoms include:
• Shortness of breath
• Chest tightness or pain
• Chronic coughing
• Trouble sleeping due to coughing or wheezing
Asthma symptoms, also called asthma flare-ups or asthma attacks, are often caused by allergies and exposure to allergens such as pet dander, dust mites, pollen or mold. Non-allergic triggers include smoke, pollution or cold air or changes in weather.
Asthma symptoms may be worse during exercise, when you have a cold or during times of high stress.
Children with asthma may show the same symptoms as adults with asthma: coughing, wheezing and shortness of breath. In some children chronic cough may be the only symptom.
If your child has one or more of these common symptoms, make an appointment with an allergist / immunologist:
• Coughing that is constant or that is made worse by viral infections, happens while your child is asleep, or is triggered by exercise and cold air
• Wheezing or whistling sound when your child exhales
• Shortness of breath or rapid breathing, which may be associated with exercise
• Chest tightness (a young child may say that his chest “hurts” or “feels funny”)
• Fatigue (your child may slow down or stop playing)
• Problems feeding or grunting during feeding (infants)
• Avoiding sports or social activities
• Problems sleeping due to coughing or difficulty breathing
Patterns in asthma symptoms are important and can help your doctor make a diagnosis. Pay attention to when symptoms occur:
• At night or early morning
• During or after exercise
• During certain seasons
• After laughing or crying
• When exposed to common asthma triggers
Asthma Diagnosis
An allergist diagnoses asthma by taking a thorough medical history and performing breathing tests to measure how well your lungs work.
One of these tests is called spirometry. You will take a deep breath and blow into a sensor to measure the amount of air your lungs can hold and the speed of the air you inhale or exhale. This test diagnoses asthma severity and measures how well treatment is working.
Many people with asthma also have allergies, so your doctor may perform allergy testing. Treating the underlying allergic triggers for your asthma will help you avoid asthma symptoms.
Treatment:
There is no cure for asthma, but symptoms can be controlled with effective asthma treatment and management. This involves taking your medications as directed and learning to avoid triggers that cause your asthma symptoms. Your allergist will prescribe the best medications for your condition and provide you with specific instructions for using them.
Controller medications are taken daily and include inhaled corticosteroids (fluticasone (Flovent Diskus, Flovent HFA), budesonide (Pulmicort Flexhaler), mometasone (Asmanex), ciclesonide (Alvesco), flunisolide (Aerobid), beclomethasone (Qvar) and others).
Combination inhalers contain an inhaled corticosteroid plus a long-acting beta-agonist (LABA). LABAs are symptom-controllers that are helpful in opening your airways. However, in certain people they may carry some risks.
LABAs should never be prescribed as the sole therapy for asthma. Current recommendations are for them to be used only along with inhaled corticosteroids. Combination medications include fluticasone and salmeterol (Advair Diskus, Advair HFA), budesonide and formoterol (Symbicort), and mometasone and formoterol (Dulera).
Leukotriene modifiers are oral medications that include montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo, Zyflo CR).
Quick-relief or rescue medications are used to quickly relax and open the airways and relieve symptoms during an asthma flare-up, or are taken before exercising if prescribed. These include: short-acting beta-agonists. These inhaled bronchodilator (brong-koh-DIE-lay-tur) medications include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex HFA) and pirbuterol (Maxair Autohaler). Quick-relief medications do not take the place of controller medications. If you rely on rescue relief more than twice a week, it is time to see your allergist.
Oral and intravenous corticosteroids may be required for acute asthma flare-ups or for severe symptoms. Examples include prednisone and methylprednisolone. They can cause serious side effects if used on a long term basis.
Visit the AAAAI Drug Guide for a complete list of medications commonly used to treat asthma.
If you are pregnant, you may be hesitant about taking medications, including those for asthma. This can be a mistake for your health and that of your baby-to-be. Continue taking your prescribed asthma medications and make an appointment with your allergist to discuss treatments that will help you have a healthy pregnancy. Additionally, you may want to enroll in a study designed to monitor medications and pregnancy.
People with asthma are at risk of developing complications from respiratory infections such as influenza and pneumonia. That is why it is important for asthma sufferers, especially adults, to get vaccinated annually.
With proper treatment and an asthma management plan, you can minimize your symptoms and enjoy a better quality of life.
2nd priority: J4552- severe asthma with status asthmatucus
Status asthmaticus is severe asthma that does not respond well to immediate care and is a life-threatening medical emergency. Ensuing respiratory failure results in hypoxia, carbon dioxide retention and acidosis. The exact mechanism underlying the development of an acute severe asthma attack remains elusive but there appear to be two phenotypes.
In deaths from asthma there is often a failure to recognise the full severity of the situation. This can be down to the patient, their family/carers or the healthcare team but often a multitude of factors is involved. Patients frequently have adverse psychosocial factors that interact with the ability to judge or manage their disease or have a diminished perception of their dyspnoea that leads to late presentation. Medical care continues to fail sometimes to treat acute severe asthma aggressively enough or to comply with national guidelines.
Status asthmaticus must be distinguished from other causes of acute breathlessness, including:
Treat at home or in the surgery and assess response to treatment.
Following initial assessments and initial treatment with oxygen, salbutamol and prednisolone or hydrocrtisone, further management will depend on the severity of asthma and response to treatment. Further treatments may include intravenous magnesium and correction of fluid/electrolyte disturbances. The patient may need to be treated in the Intensive Care Unit (ICU).
Not all patients admitted to the ICU need ventilation, but those with worsening hypoxia or hypercapnia, drowsiness or unconsciousness and those who have had a respiratory arrest require intermittent positive pressure ventilation. Intubation in such patients is very difficult and should be performed by an anaesthetist or ICU consultant.
Evidence on the efficacy of bronchial thermoplasty for severe asthma shows some improvement in symptoms and quality of life, and reduced exacerbations and admission to hospital
3rd Priority: J440 - Chronic obstructive pulmonary disease
Your doctor will diagnose COPD based on your signs and symptoms, your medical and family histories, and test results.
Your doctor may ask whether you smoke or have had contact with lung irritants, such as secondhand smoke, air pollution, chemical fumes, or dusts.
If you have an ongoing cough, let your doctor know how long you've had it, how much you cough, and how much mucus comes up when you cough. Also, let your doctor know whether you have a family history of COPD.
Your doctor will examine you and use a stethoscope to listen for wheezing or other abnormal chest sounds. He or she also may recommend one or more tests to diagnose COPD.
Pulmonary Function Tests
Pulmonary function tests measure how much air you can breathe in and out, how fast you can breathe air out, and how well your lungs deliver oxygen to your blood.
The main test for COPD is spirometry. Other lung function tests, such as a lung diffusion capacity test, also might be used. Read Pulmonary Function Tests for more information.
Spirometry
During this painless test, a technician will ask you to take a deep breath in. Then, you'll blow as hard as you can into a tube connected to a small machine. The machine is called a spirometer.
The machine measures how much air you breathe out. It also measures how fast you can blow air out.
Spirometry- The spirometer measures the amount of air breathed out. It also measures how fast the air was blown out
Your doctor may have you inhale, or breathe in, medicine that helps open your airways and then blow into the tube again. He or she can then compare your test results before and after taking the medicine.
Spirometry can detect COPD before symptoms develop. Your doctor also might use the test results to find out how severe your COPD is and to help set your treatment goals.
The test results also may help find out whether another condition, such as asthma or heart failure, is causing your symptoms.
Other Tests
Your doctor may recommend other tests, such as:
ICD 10 CODES:
J440 Chronic obstructive pulmonary disease with acute lower respiratory infection J441 Chronic obstructive pulmonary disease with (acute) exacerbation J449 Chronic obstructive pulmonary disease, unspecified J4520 Mild intermittent asthma, uncomplicated J4521 Mild intermittent asthma with (acute) exacerbation J4522 Mild intermittent asthma with status asthmaticus J4530 Mild persistent asthma, uncomplicated J4531 Mild persistent asthma with (acute) exacerbation J4532 Mild persistent asthma with status asthmaticus J4540 Moderate persistent asthma, uncomplicated J4541 Moderate persistent asthma with (acute) exacerbation J4542 Moderate persistent asthma with status asthmaticus J4550 Severe persistent asthma, uncomplicated J4551 Severe persistent asthma with (acute) exacerbation J45901 Unspecified asthma with (acute) exacerbation J45902 Unspecified asthma with status asthmaticus J45909 Unspecified asthma, uncomplicated J45990 Exercise induced bronchospasm J45991 Cough variant asthma J45998 Other asthmaRelated Questions
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