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-=-=-=-=-=> [這篇文章最後由JuanFe在 2018/05/11 07:12pm 第 1 次編輯] ASTHMA FOLLOW UP Doorway information about patient The patient is a 22 years old woman who comes to the clinic for follow up of asthma. Vital signs .Temperature 36.8’C .Blood pressure 118/68 mm Hg .Pulses 84/Min .Respirations : 16/min Approach to the patient Asthma should be specific as intermittent (daytime symptoms <=2 days a week , nighttime symptoms <=2 times a month) or persistent . Persistent asthma can be further specific as : . Mild: Symptoms 2-6 days a week with minimal limitation in activity. . Moderate : Daily symptoms wit noticeable limitation in activity. . Severe ; constant o near-0 constant symptoms with significant limitation in activity The evaluation should focus on identifying patient at risk for exacerbation and varying that they are taking appropriate preventive measures. The patient encounter has 4 primary components: . Assessment of current symptoms . Object evolution of disease status (eg.peak expiration flow rate ) . Risk stratification based o the patient’s history and current status. . Interventions , including medications , vaccines , and education , to mitigate the risk. Review the patient’s current treatment and discuss whether it is working , is well tolerated , and is appropriate to the patient;s risk. In general , asthma with only mild , Intermittent symptoms can be managed with a short- acting beta agonist as need . patient with persistent symptoms should also receive a low-dose inhaled glucocorticoid (at a minimum). Different diagnosis The diagnosis may need to be reconsidered if the patent’s condition is worsening despite appropriate treatment . Possibilities include : . The origginal diagnosis is incorrect or incomplete . . the diagnosis is correct , but the treatment is inappropriate of inadequate for the patient . The diagnosis and chronic treatment are correct , but an acute problems has caused decomposition in the patient’s condition. Asthma symptoms may be exacerbated due to acute infection or enviromental triggers , such as smoking or seasonal pollen . Also patent may be noncompliant with therapy or using inhalers incorrectly. History and physical examination Patient with chronic conditions are often well educated on their condition and familiar with the questions the physicians is likely to as . begin with a broad , open-ended questions and give the patient time to answer without interrupting History History of present illness . how are you doing with your asthma ? . when was your asthma first diagnosed ? . What symptoms are you having ? Wheezing / coughing ? shortness of breath ? . How often have you had symptom during the day ? at night ? . What is your current medical program? . What treatment have you been on in the past ? Why is your treatment changed ? . How often are you using your rescue inhaler ? . Can you show me how you use the inhaler ? .Do you check your pick flow at home ? Hw do your recent readings compare with your personal best ? . What things (eg. infections , pollen, dust , cold air ) trigger your asthma ? . have you ever taken oral corticosteroids for asthma ? when was the last time ? . overall , do you think your asthma is getting better or worse ? Past medical history . What other medical conditions have you had ? . Did you receive an influenza vaccination this season ? . have you received a vaccine for pneumococcal; pneumonia ? Social history . Do you smoke ? When didi you start and how much do you smoke ? . Do you drink alcohol? How much and how often? . Have you used illicit drugs ? The physical examination for patient with chronic illness is often very brief . however , if the patient is doing poorly a more extensive examination is warranted. Physical examination general . Examine body habits. . Assess level of distress HEENT . Examine ears with otoscope . Examine nasal mucosa . Examine pharynx for thrush (possible complication of inhaler glucocorticoids). Cardiovascular . Auscultate heart. Pulmonary . Evaluate respiratory rate & depth as well as accessory muscle use . . Estimate time for inspiration compared with expiration (normal 2:3) . Auscultate both sides , front and back . Percuss upper , middle & lower lung fields bilaterally. Closing the encounter The wrap up discussion should being with a summary of your findings and assessment of the patient’s risk for a severe asthma exacerbation . Encourage the patient to discuss any concerns about current management , and review plans for addressing any exacerbation they may experience between office visit (asthma action plan) . Discuss whether the asthma is table and the current management is adequate or whether it is unstable and management should be changed. If the patient smokes , assess readiness to quit. Diagnostic studies All patients with asthma should have as objective assessment of physiologic lung function . In most cases , this is accomplished with bedside measurement of peal expiratory flow ate . Spirometry is not performed at every visit but should be considered if the patient has ongoing symptoms or has responded to therapy as expected. other test may include; . pulse oximetry (if no provided ) or arterial blood gas analysis . complete blood count . chest x ray ( if the patient has abnormal examination findings other than wild wheezing ) Advanced imaging (eg. CT scan ) ind invasive studies (eg. bronchoscopy ) are not usually performed in the initial assessment. -=-=-=-=-=>
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