Shortness of Breath or Difficulty Breathing Discussion Essay Paper

Shortness of Breath or Difficulty Breathing Discussion Essay Paper

Week 3 Case Study: Respiratory

 

Instructions:

• Use the Case Study Template to complete. Download Use the Case Study Template to complete.
• Be sure to include at least one reference.
• Include in-text citations as needed.

Select one case to discuss.  

• Case 1: A 9-year-old female presents with her mother complaining of a dry cough that “wakes up everyone in the house” each night for the last two weeks.
• Case 2: A 29-year-old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.
• Case 3: A 38-year-old artist has smoked since she was 18 years old. She has noticed a mild, occasionally productive cough for the past few months. On a recent trip to the mountains, she developed shortness of breath that caused her to be nauseated. She has had no fever or chills. Her medical history includes hypertension for which she is using lisinopril, metoprolol, and hydrochlorothiazide. Shortness of Breath or Difficulty Breathing Discussion Essay Paper
  

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Physical Assessment

Case Study Template

Name: ________________________________________

Week of Class (1-8): ______

Body System focus area (i.e., cardiovascular): _____________________________

Case Study:  A 9-year-old female presents with her mother complaining of a dry cough that “wakes up everyone in the house” each night for the last two weeks

Questions (if data is unavailable, indicate “unavailable”):

1. What is the client’s chief complaint?

Dry cough that disrupts sleep and wakes up everyone in the house each night for the past two weeks. Shortness of Breath or Difficulty Breathing Discussion Essay Paper

2. What questions would you ask the client?
   • HPI (history of present illness):
     • When did the cough first start?
     • Has the cough been continuous or does it come and go?
     • How often does the cough occur? Is it only at night or does it happen during the day as well?
   • ROS (review of systems):
     • Have you noticed any other symptoms besides the cough?
     • Do you have a fever?
   • Medical/Surgical/Psych History:
     • Have you been diagnosed with any medical conditions or have any chronic illnesses?
     • Have you had any recent surgeries or hospitalizations?
   • Family History
     • Has anyone else in your family experienced similar symptoms or chronic cough?
     • Are there any family members with a history of allergies, asthma, or respiratory conditions?
   • Other:
     • Are you exposed to secondhand smoke at home or elsewhere?
     • Have you traveled recently, especially to areas with a different climate or air quality?

3. What physical examinations would you include? Shortness of Breath or Difficulty Breathing Discussion Essay Paper

Body System	Include? ü (yes) or – (not indicated)	Notes
General survey	ü	Observe and assess the overall appearance and behavior of the patient. Evaluate the patient’s posture, body habitus, level of distress, and overall hygiene.
HEENT (head, eyes, ears, nose, throat/thyroid)	Not indicated
Cardiovascular	ü	Auscultate heart sounds (stethoscope to actual skin)
Peripheral Vascular	Not indicated Shortness of Breath or Difficulty Breathing Discussion Essay Paper
Breasts	Not indicated
Lymphatic
Pulmonary	ü	Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior
Gastrointestinal/Abdominal	Not indicated
Genitourinary/Pregnancy	Not indicated
Integumentary	Not indicated
Musculoskeletal	Not indicated
Neurological	Not indicated

 

4. What are pertinent positive physical assessment findings?

• Presence of a dry cough that disrupts sleep and wakes up everyone in the house each night for the last two weeks.
• Abnormal lung sounds on auscultation (e.g., wheezing, crackles).

5. What are the pertinent negative physical assessment findings?

• Absence of fever.
• Absence of shortness of breath or difficulty breathing.
• Absence of chest pain or discomfort.

6. What are at least 3 differential diagnoses?
   • Whooping cough
   • Asthma
   • Upper respiratory infection (URI)
7. What is your primary diagnosis? Shortness of Breath or Difficulty Breathing Discussion Essay Paper

• Whooping cough

8. What is your treatment plan?
   • Diagnostic procedures: Pulmonary function tests (spirometry) to assess lung function or allergy testing to identify specific allergens triggering the cough.
   • Labs: Complete blood count (CBC) and allergy tests
   • Client education (including lifestyle modifications, if applicable):
     • Educate the client and her mother about the likely causes of a dry cough, such as allergic cough or asthma. Provide information on triggers to avoid, if identified (O’ Neill, 2019).
     • Teach proper cough etiquette, such as covering the mouth and nose with a tissue or elbow when coughing or sneezing.
   • Pharmacotherapy (including complementary and alternative therapies):
     • Antihistamines or nasal corticosteroids may be prescribed to reduce allergic symptoms and alleviate the cough (O’ Neill, 2019).
     • Inhaled bronchodilators (such as short-acting beta-agonists) and inhaled corticosteroids as maintenance therapy to control symptoms and prevent exacerbations.
     • Homeopathic treatments, for cough management
   • Health promotion (preventative care, anticipatory guidance):
     • Promote preventive care measures such as ensuring the child is up to date on vaccinations, including influenza and pertussis vaccines, to reduce the risk of respiratory infections.
     • Encourage a healthy lifestyle, including a balanced diet, regular exercise, and adequate sleep, to support overall respiratory health and immune function.
     • Educate the client and her mother about recognizing and avoiding triggers, such as smoke, strong odors, or known allergens.
     • Emphasize the importance of maintaining good hand hygiene and respiratory etiquette to prevent the spread of infections.
   • Follow-Up:
     • Follow up after 2 weeks to monitor the progress of symptoms and assess the effectiveness of the treatment plan. Shortness of Breath or Difficulty Breathing Discussion Essay Paper

References

O’Neill, J. (2019). Cough and breathlessness. Oxford Handbook of Humanitarian Medicine, 375-380. https://doi.org/10.1093/med/9780199565276.003.0024 Shortness of Breath or Difficulty Breathing Discussion Essay Paper