Scribd
Upload
55 views1 page

Asthma Case Study Report

A 19-year-old female patient presented to the emergency room with difficulty breathing. She had a history of asthma since childhood, experiencing attacks 3-4 times per year. On December 12th, she developed cough, wheezing, and dyspnea. She used her salbutamol inhaler with slight relief but had three severe asthma attacks that night, becoming pale and more short of breath each time. She was brought to the emergency room in respiratory distress and remained dyspneic even after multiple nebulizer treatments. The patient has a family history of asthma in her siblings and on both sides of her family. A physical exam found pallor, wheezing, and supraclavicular retractions

Uploaded by

Patrick Dycoco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
55 views1 page

Asthma Case Study Report

A 19-year-old female patient presented to the emergency room with difficulty breathing. She had a history of asthma since childhood, experiencing attacks 3-4 times per year. On December 12th, she developed cough, wheezing, and dyspnea. She used her salbutamol inhaler with slight relief but had three severe asthma attacks that night, becoming pale and more short of breath each time. She was brought to the emergency room in respiratory distress and remained dyspneic even after multiple nebulizer treatments. The patient has a family history of asthma in her siblings and on both sides of her family. A physical exam found pallor, wheezing, and supraclavicular retractions

Uploaded by

Patrick Dycoco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Date of Interview: December 13, 2011

Source of Information: Patient


Reliability: 95%
Source of Referral: None
Identifying Data:
Borer, Elma
19 yrs old
married
Alang-alang Leyte
Roman Catholic
DOA: Dec 13, 2011/4 am, 1st admission
Chief Complaint: Difficulty of breathing
History of Present Illness:
Dec 9, 2011
Colds for 3 days
No fever
No meds taken
Dec 12
8pm
Cough productive of whitish sputum,
tspoon/cough
Sorethroat
Headache, PS of 2/10
9pm
Persistence of the above s/sx
1st asthma attack: dyspnea, wheeze
Dyspnea decreased in severity with sitting
position, aggravated by supine position
Sleeps leaning on the wall
Salbutamol thru inhaler with slight decrease
in severity of dyspnea
Pt slept for 30 mins after taking salbutamol
9:30pm
2nd asthma attack, pallor
Salbutamol
11pm
3rd asthma attack, pallor
Increased in severity of dyspnea
Salbutamol inhaled (last dose)
Dec 13
1am
Due to consumed salbutamol, pt was rushed
to the RHU for nebulization
LOC upon arrival for 30 mins
Nebulization was continued until the pt
gained consciousness
After 3 series of nebulization, pt was still
dyspneic hence brought to EVRMC
Past History:
Childhood Illnesses: 5 years old, onset of asthma. 3-4
attacks/ yr but had never hospitalized due to asthma.
2-3 RHU visits/yr.

Adult Illnesses:
Medical: asthma attack every other month which
usually lasting for 30 mins-1 hr . Such pattern started
in highschool. 1 tab 400 mg ansinar, 1 tab 20 mg
pred20, and salbutamol, all 2 x a day/attack
Surgical: none
Psychiatric: None
Immunization: unrecalled. BCG scar at R deltoid
Allergies: allergic to egg, chicken, shrimp, crabs, no
known allergy to drugs
Family History:
Mother: 44 yo, healthy
Father: 49 yo, healthy
Siblings:
1st: 23, f, no asthma, healthy
2nd: 21, f, asthmatic
3rd: pt
4th: 17, F, asthmatic
5th: 14, M, asthmatic
6th: 11, M, asthmatic
7th: 6, M, asthmatic
Heridofamilial dses: asthma on both sides
Personal and Social:
Pt, 19 yo, housewife, highschool grad
Husband, 24 yr, farmer, highschool grad
Concrete house located ___meters away
from the ricefield. With water sealed toilet
and electricity. Water source is from a
communal faucet not boiled prior to
drinking. Cook with the use of firewood done
inside the house. Household wastes
collected by a garbage truck every week.
House is clean, no dusts.
No domestic pets
Pt and husband are nonsmoker and
nonalcoholic beverage drinker
No exercise
Usual diet: rice, fish, vegetable. Avoids
foods like chicken, egg, milk, shrimp, crabs,
Wakes up at 6am, sleeps at 9 am
PE
VS:
temp 36.8
RR: 34
PR: 106
BP: 110/80
Pallor
Supraclavicular retractions
Wheeze in all lung field
Apex beat at 6th ICS
Heart beat is regular

(-) murmur

You might also like