BRIAL FAITH VENICE C.

TIBONG

BSRT – 4

CASE STUDY: ASTHMA

A 25-year-old African American with a history of moderate persistent asthma. He is being admitted to
the hospital from the walk-in clinic with an acute asthma exacerbation. Patient has an increased chest
tightness and shortness of breath one day prior to admission. In the walk-in clinic patient is alert,
speaking in short sentences due to breathlessness at rest. Patient has prolonged respiratory rate and
present with wheezes throughout both lung fields with decreased breath sounds at the right lung. His
oxygen saturation on room air is 90%. His color is ashen, and he has dark circles under his eyes. He is
sitting upright and using his accessory chest muscles to breath and has moderate intercostal and
substernal retractions. He is complaining of tightness in his chest. Patient was diagnosed with asthma at
age 6 years. He has three prior hospitalizations for asthma with one admission to the intensive care unit
within the last 5 years. He has never had to be intubated with these episodes. Patient denies tobacco
smoke at home.

SUBJECTIVE:

Chief Complaint:

- Patient is speaking in short sentences due to breathlessness at rest.

- Patient has prolonged respiratory rate and present with wheezes throughout both lung fields
with decreased breath sounds at the right lung.
- Patient is complaining of chest tightness

History of Present Illness:

- Patient was diagnosed with asthma at age 6yrs.

- He has 3 prior hospitalizations for asthma with one admission to the ICU within the last 5 years.
- He has never had to be intubated with these episodes.

Past Medical History:

- Not stated

Family History:

- Not stated

OBJECTIVE:

Temperature: 37.7C

Pulse Rate: 99/min

Respiratory Rate: 30/min

Blood Pressure: 114/78

O2 Saturation: 90% on room air

Physical Examination:

1. General Appearance:
- His color is ashen, and he has dark circles under his eyes. He is sitting upright and using his
accessory chest muscles to breath and has moderate intercostal and substernal retractions with
increased respiratory rate.
- Only able to talk in short sentences due to breathlessness.
2. Chest:
- Wheezes present bilaterally.
3. Lungs:
- Breath sounds with inspiratory and expiratory wheezing and prolonged expiration. Has tight-
sounding non-productive cough, decreased breath sounds in right lung.
4. Extremities:
- Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal beats,
pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

ASSESSMENT:

- Patient shows signs of anxiety, distress due to inability to breath.

- Diaphoresis due to physical stress and use of accessory muscles.
- Wheeze sounds when breathing is a sign of an asthma attack
- May have accumulation of fluids on lower base of right lung
- Pt alert, conscious, cooperative
- Strong heart
- No signs of skin or urinary infections.

PLAN:

- Vital signs every 1 hour and as needed

- Continuous oxygen saturation monitoring, apply O2 via nasal cannula at 2lpm, titrate if needed.
Monitor O2 sat >93%
- Albuterol 2.5 mg and ipratropium bromide 0.25 mg via face mask nebulizer every 20 minutes as
needed for respiratory distress
- Methylprednisolone IV loading dose 2mg/kg then start Methylprednisolone IV (steroid should
be used to decrease inflammation)