Question

Asthma Case Study Assignment

9) Write (document) utilizing the information, medical history, vital signs, etc. presented on this case study BELOW, to communicate to other care providers who will also care for this same patient: [Hint: SBAR (Situation, Background, Assessment, Recommendation) and SOAP (Subjective, Objective, Assessment and Plan)

A) SBAR

B) SOAP

B) SOAP

History

Ms. B is a 19 year old competitive bronco rider seen in the emergency room because of shortness of breath. The dyspnea began during a particularly hard ride, which culminated in modest dust inhalation on the rodeo floor. She states that the tightness in her chest and shortness of breath were so severe that she had to eventually leave the rodeo and see medical help. She is now very uncomfortable, even at rest. During the past week she has had a cough productive of greenish yellow sputum, mild fever, malaise, and fatigue, but she did not feel seriously ill until the onset of dyspnea at the rodeo earlier in the day. She denies previous lung problems except for mild ‘wheezing’ in her chest, which has occurred off and on during the past several years. She denies the use of any prescription medications, or any previous episodes of dyspnea, chest pain, leg pain, hemoptysis, sinusitis, or allergies. Her family history is negative for lung disease.

Physical Examination

General: 19 year old, 66 inches tall, and 140 lbs. Patient alert but restless and in moderate respiratory distress, mildly diaphoretic, sitting up on the edge of the bed leaning forward with her arms braced on her knees; cough frequent and productive of small amounts of greenish sputum.

Vital Signs: Temperature 101.1 F, Respiratory Rate 38/min, Blood Pressure 170/95 mmHg, Heart Rate 140/min, Paradoxical Pulse 25mmHg.

HEENT: Sinuses not tender to palpation; nasal flaring with inspiration

Neck: Trachea midline and mobile to palpation; no stridor; carotid pulsations + + and symmetrical bilaterally with no bruit; no lymphadenopathy, thyroidomegaly, or jugular venous distention; sternocleidomastoid muscles tensed during inspiration.

Chest: Increased anteroposterior diameter with decreased expansion during breathing and mild abdominal paradox with respiratory efforts.

Lungs: Rapid respiratory rate with prolonged expiratory phase and polyphonic wheezing heard over entire chest during inhalation and exhalation.

Heart: Regular rhythm at 140/min; no murmurs, gallops, or rubs; point of maximum impulse in normal position.

Abdomen; Soft, nontender; bowel sounds present; no masses or organomegaly.

Extremities; No clubbing, cyanosis, or edema; pulses + + and symmetrical in all areas

Answer 1

SBAR Documentation

Situation	19 years old patient admitted with shortness of breath. She states that the tightness in her chest and shortness of breath were so severe. She is now very uncomfortable, even at rest.
Background	She had a cough productive of greenish yellow sputum, mild fever, malaise, and fatigue.
Assessment	Findings may suggest for respiratory tract infection The respiratory problems can lead to pulmonary arterial vasoconstriction. This leads to hypertension
Recommendation	Sputum culture and sensitivity is needed to identify the nature and type of infection After that antibiotic therapy is needed.

SOAP Documentation

Subjective	Patient reported shortness of breath. She states that the tightness in her chest and shortness of breath were so severe.
Objective	Frequent cough and productive of small amounts of greenish sputum. sternocleidomastoid muscles tensed during inspiration. Rapid respiratory rate with prolonged expiratory phase and polyphonic wheezing heard over entire chest during inhalation and exhalation Vital Signs: Temperature 101.1 F, Respiratory Rate 38/min, Blood Pressure 170/95 mmHg, Heart Rate 140/min.
Assessment	She is now very uncomfortable, even at rest. She has moderate respiratory distress, mildly diaphoretic, sitting up on the edge of the bed leaning forward with her arms braced on her knees and she is suffering from frequent cough and productive of small amounts of greenish sputum.
Plan	Sputum culture and sensitivity is needed to identify the nature and type of infection After that antibiotic therapy is needed.