Background:

BIODATA

Name: James Smith

Age: 5 ½ years

Sex: Male

Ethnicity: Black African

Residence: St. Louis Missouri

Next of Kin: Mary Smith

Relationship with next of kin: Mother

Next of kin cellphone: 0723310923

PRESENTING COMPLAINS:

Patient presented with difficulty in breathing, wheezing, sweating and lethargy which had begun in the morning (5 hours before seeking care).

HISTORY OF PRESENTING COMPLAIN:

Patient was well until the morning when he developed the above complains. He woke up and took breakfast which comprised an egg, banana and white tea.  Later he visited construction site for a residence the family is building.  He visited the stores to pick a material for one of the construction workers.  After approximately 30 minutes, he returned to the house to bath since they had planned a trip to visit his Father at work.  The developed labored breathing on the way out but her mother opted to continue with the journey and visit a hospital later. However, wheezing worsened she had to stop the journey and seek a nearby hospital.

PAST MEDICAL SURGICAL HISTORY

Patient has had one episode of asthmatic attack at the age of 2 years but it resolved within a year of medication. No other chronic illness, or allergy has been noted. He has never been operated.

SOCIAL HISTORY

He is a third born in a family of five. He is in grade KG. His performance in school is impressive, he is playful and active class representative.  He lives with his mother. The other siblings are in boarding schools.

Physical Assessment:

OBSERVATION OF VITAL SIGNS

Temperature: 37.4Oc (36.2 Oc -37.2 Oc, Pulse rate 83 beats/min (60-110, Respiratory rate 30(20-40) beats/min, Blood pressure 127/67 mmHG.

Focused Assessment:

Generally, the patient was ambulating, conscious but strained to walk fast. No abnormalities were noted on the skin. Head and neck showed nothing significant. However, there was labored breathing. Auscultation of the chest showed wheezing on expiration. The abdominal muscles were involved in expiration of air.  Extremities were normal although there was a tinge of cyanosis on the lower extremities.  Oxygen saturation on the upper extremities was averagely 89.0C.

DIAGNOSIS

The history presented as well as physical assessment findings were indicative of respiratory tract problem associated with narrowing of airways.  Such conditions included Asthma, pneumonia and bronchiolitis.  Additional tests were conducted to include an X-ray to rule our pneumonia. The test was negative for pneumonia. Exhaled Nitric Oxide test shows 23 parts per billion confirming inflammation of the airway. The acute nature of the condition lead to conclusion of Asthmatic Attack diagnosis.

PATHOSPHYSIOLOGY

Asthmatic attack occurs when an allergen activates inflammatory response in the body thus causing inflammation, swelling and accumulation of fluid along the airways. The airways are narrowed by the accumulated fluid and inflammation, necessitating a forceful breathing out (expiration) which ought to be an effortless in normal circumstances.  This impairs gaseous exchange at the alveoli leading to reduced oxygen saturation in blood and tissues, which is responsible for myalgia and lethargy.

If no intervention is done, the asthma associated inflammation leads to loss of lung function with time leading to development of comorbidities such as Congestive Pulmonary Disease and bronchiectasis.  Public health considerations involve removal of allergens from the environment in order to minimize risks of Asthmatic attack.

ASSESSMENT

The identified problem was that the patient was not fully informed asthmatic attacks could re-occur in future. This was the second time the patient was treated for Asthma.  One of the key approaches to management of Asthma is avoidance of the allergen. But the patient in this case believed they were healed and never anticipated another episode of attack would occur with another exposure.  A visit to the construction store, which often is dusty and houses cement among other items was the potential source of the allergen that lead to development of Asthma.  Besides, there was inappropriate prescribing and monitoring of patients. Patients diagnosed with Asthma are required to keep inhaler medications and to be conversant with asthma symptoms. This is meant to ensure they can assess emergency care wherever the condition happens.  In this case, they lacked the know-how as well as the drugs to manage the situation at home.

EVIDENCE

Guidelines for management of Asthma require a systematic approach to ensure quality care and effective management. The first approach is correct diagnosis of Asthma patients and identification of allergens.  The second step is management of the acute phase with medications that reduce inflammation of the airway as well as reduce secretions on the airway. The third step is education of the patient to improve their knowledge on the causes, pathophysiology, management and prevention of Asthma.  Lastly is removal of the allergen and educating the patient on identification and avoidance of the allergen.

CONCORDANCE

Development of concordance relationship with the client begins on clear education of the problem they are suffering from and developing an open relationship on the nature of the condition and how it can be managed and/or prevented. Besides, establishing an agreement for regular clinic visits to provide follow up and encourage regular discussion would improve the relationship. I will encourage self care by educating the client to have an inhaler medication in the house for use during such episodes. Besides, I will share hospital contact information to enable client seek help from home by way of phone consultation.

PHARMACOECONOMICS

There are no cheaper drugs for managing Asthma. However, it is necessary to ensure the child has an insurance cover. Secondly, prevention of allergen is the best approach to minimize costs associated with Asthma attack. Moreover, self-medication with inhaler medications can reduce hospital consultation costs

CLINICAL GOVERNANCE

LEGAL ASPECTS

ETHICAL ASPECTS

RECOMMENDATIONS

I recommend that management of Asthmatic patients to be broadened to include more education on prevention of non-allergens. I recommend that Asthmatic patients should be allowed to consult from their homes to manage acute episodes because transfer to hospital consumes more time.  Patient follow up after the first episode of attack is necessary. A bi-annual visit to the clinic even in the absence of asthma signs and symptoms is necessary to allow evaluation of client progress and knowledge of the condition.

Communication

We agreed with the client to continue with a follow up clinic  the following week.  I kept records of the