Initial Evaluation

General Information
Patients Name: R.E.A
Age: 46 y/o
Sex: Female
Address: Pugo, Bauang, La Union
Civil Status: Married
Citizenship: Filipino
Handedness: Right handed
Occupation: Lawyer and Part-time Instructor
Religion: Catholic
Referring Unit: IPD
Referring Dr.: Dr. B.R.
Rehab Dr.: N/A
Date of Referral: N/A
Date of Consultation: Sept. 16, 2016
Date of Evaluation: November 10, 2016
Diagnosis: Acute Respiratory Failure 2 to severe exacerbation of
Bronchial Asthma
S:
c/c:
Pt. verbatim: Nahihirapan ako huminga, sumisikip and dibdib ko
Nagpu-puff ako ng Symbicort (2/3 puffs a day) para matanggal ang
nararamdaman ko. Lumalala pag nakakalanghap ako ng usok at
alikabok.
PT Translation: Pt c/o difficulty of breathing and narrowing of airway.
It is alleviated by sniffing from a Symbicort puff for 2/3 puffs a day. Ans
is aggrevated by breathing in smoke and dust.
HPI:
Present condition started 2 mo PTIE when pt. had dry cough and
colds which was assumed to be acquired from her husband who also
have dry cough and colds for ~ 2 wks. The dry cough and colds are
aggravated by exposure to smoke, dust and air pollution. And these
symptoms are relieved by taking Congestril Forte 325 mg. tid for dry
cough and colds. p taking Congestril Forte 325 mg, pt felt that the dry
cough and colds are lessened for ~4hrs. Based on pt.s past
experience, dry cough and colds may trigger her asthma which she
have since she was an infant. p 3 days of taking Congestril Forte 325
mg tid, the dry cough and colds are still not resolved. While on her way
going to work c her husband who is driving, pt felt that her airway in
breathing is progressively narrowing which causes her to have difficulty
in breathing. This condition is alleviated by inhaling Symbicort which
was prescribed by Dr. B.R. 2 yrs. ago. And is aggravated by inhaling

smoke and dust. When pt.s husband observed that the symptoms of
asthma that the pt. is experiencing becoming worse, he immediately
rushed his wife to ITRMC Emergency Department which is the closest
hospital they can go along their way.
Pt was attended by Dr. B.R. who immediately prescribed
Duavent 5 mL to be inhaled through a nebulizer to help the pt. have a
relief in difficulty of breathing and progressively narrowing of airway. p
~15 mins, of inhaling 15 mL Duavent, pt felt that her breathing is
slightly improved for ~ 1 hr but is not enough to breath normally.
Dr. B.R. requested for chest PA x-ray, ABG analysis and
hematology tests (see AP) as part of the hospitals protocol. p
undergoing to the tests requested by Dr. B.R. and to the assessment
conducted by Dr. B.R., pt was diagnosed c Acute Respiratory Failure 2
to severe exacerbation of Bronchial Asthma and HTN Stage II, JNC8. pt
was advised to be admitted for further treatment and observation.
Pt was admitted for 3 days in a private room in ITRMC which is
an airconditioned room located on the second floor. She was given
medications (unrecalled) administered through IV and oxygen as a
management prescribed by Dr. B.R. During the 3 days of duration of
admission in the hospital, pt. was advised to be on bedrest. Pt
visitation and talking is also prohibited to the pt. by the doctor as much
as possible to prevent the patient to get tired and to get enough rest.
But pt abides to the doctors advice. Pt also had visitors but are only
limited to 2 visitors a day and pt is also talking but is only very limited
when needed. During the 3 days of admission, pt was very weak. Pt
can only walk for ~ 10 steps for 5 mins performed only when going to
bathroom.
p the pt was D/C, pt was advised to rest for 7 days and was
given some medications (see medications). As a part-time instructor
she was also advised to use white board marker than chalk to prevent
the asthma to be triggered. Pt cannot perform some IADL that she
usually do before the onset of symptoms such as going to market,
cleaning the house and cooking. Also, when she works as an instructor
she easily gets tired p 2 hrs. of class which is unusual for her.
At present, pt cannot still perform the IADL that she can perform
before the onset of symptoms such as going to market, cleaning the
house, and cooking.
Ancillary
Procedure
Chest AP x-ray

Date/ Hospital

Hematology
ABG Analysis

9/16/16/ ITRMC
9/16/16/ ITRMC

Medications
Budesonide 320 mg
Salbutamol +
Ipartropum 1 neb
Cefuroxime 500 mg
Feledipine 5 mg
Aprovel 200 mg

9/16/16/ ITRMC

Findings/
Interpretation
(+)Hazy infiltrates
are seen in both
lower lungs
No sig. findings
Increased pO2

Indication
Bronchodilator
Bronchodilator

Dosage
bid
qd

Antibiotic
Calcium Channel
Blocker
Angiotensin II receptor
anatagonist

bid
qd
bid

PMHx:
(+) Hospitalization (see Hospitalization)
(+) Bronchial Asthma
(+) HTN
(-) DM
(-) Heart Dse
Hospitalizations
Date
2 years ago
(unrecalled)
September 16, 17,
18

Hospital
Bethany Hospital

Reason
(+) Bronchial Asthma

ITRMC

(+)Acute Respiratory
Failure 2 to severe
exarcerbation of
Bronchial Asthma
(+) HTNStage II, JNC8

FMHx:
Asthma
HTN
Heart Disease
DM

F
(-)
(-)
(-)
(-)

M
(+)
(+)
(+)
(-)

PSHx:
Pt. has an active lifestyle. She exercises daily by jogging for ~5
kms for 45 mins while praying the Holy Rosary. At present, pt is a nonsmoker but she has a hx of smoking for ~ 2 sticks a day when she was
reviewing for bar exams for 6 mo while drinking coffee to stay awake
until 2:00 a.m. Pt is a non-alchoholic beverage drinker and has no hx of
substance abuse. Pt lives in a two storey house along a barrio street c
her husband, 2 sons and 2 stay-out helpers. Pt. stated that their house
is near to a poultry farm. No one who is living in their house who
smokes. Pt bedroom is located upstairs ~ 30 steps from main door to
bedroom and ~ 10 steps on the stairs.

Goal:
Pt. verbatim: Mawala ang sakit ko.
PT Translate: Pt.s goal is to resolve her asthma condition.
O:
VS
BP: 120/80mmhg
PR: 76 bpm
RR: 18 cpm
T: 36.4 C

OI
amb s AD
A/C/C
Ecdomorph
(+) Postural Deviation (see postural Analysis)
(-) Swelling
(-) Trophic skin changes
(-) Gait Deviation
(-) Deformities
(-) Digital Clubbing
Palpation:
afebrile to touch
Normotonic on all major m of B UE/ LE
(+) Increased tactile fremitus on A/P R upper lobe
(-) Tenderness
(-) Muscle Spasm
(-) Edema
(-)Chest wall pain
(-)Mediastinal shift
(-)Muscle Spasm
Mediate Percussion:
(+) dull and flat sound
Auscultation:
Findings:
(+) adventitious wheezing on T2, T6, and T10 landmarks
Significance:
2o to Bronchial Asthma
Respiratory Assessment:
Breathing Pattern: Upper Chest Breather
Coughing Mechanism: Weak Functional

Significance: pt had experienced difficulty in breathing when coughing and

when trying to excrete secretion.
Chest Expansion:
Findings:
Landmar
Maximum
Maximum
Differenc
ks: (cm)
Inhalation
Exhalation
e
Axilla
65 cm
63 cm
2 cm
Xiphoid
72 cm
71 cm
1cm
Process
Sig.: decreased chest expansion 2 to acute respiratory failure

Neurologic Evaluation:
Sensory Testing:
Device Used: Pin for pain, brush for light touch, thumb for deep pressure
Findings: 100% intact Sensation
Significance: For baseline purposes
DTR:
R

++

++
++

++

++
++
++

++

++

Legend:
areflexia
+ hyporeflexia
++
normoreflexia
+++ hyperreflexia
++++ clonus
0

++

Findings: All reflexes are normal

Significance: Intact reflex arc
ROM:
Findings: All major muscle groups of cervical and (B) UE and LE are WNL,
actively and passively done pain free and with normal end feel.
Significance: For baseline purposes

MMT:
All major muscle groups of cervical and (B) UE and LE are grossly graded 5/5
except for the ff:
Trunk Flexor : 4/5
Trunk extensor : 4/5
Findings: Pt has weakness on trunk flexor and extensor
Significance: 2 to postural deviation

Postural Assessment
Pt was assessed in standing position in Ant., Post., and Lat views and
are found to be in N alignment except
Findings:
Ant. View
R clavicle is higher than the left
Lat. View
Pt. has round back posture
Significance:
Pt has postural deviation 2 to difficulty in breathing
Functional Analysis:
ADLs

FIM LEVELS

Self-care

No Helper

Feeding: 7

7 - Complete Ind.

Grooming: 7

6 - Mod Ind.

Dressing: 7

5 - Min Ind. (subject 100%)

Bathing: 7

4 - Modified Dep, Min. Asst

Toileting: 7

3 - Modified Dep, Mod. Asst

(75%)
(50%)
Bed mobility

2 - Complete Dep, Max

Asst (25%)
Roll to right: 7
Asst (<25%)

1 - Complete Dep, Total

Roll to left: 7
Supine to sit: 7
Sit to supine: 7
Ambulation: 7
6-minute Walk Test
Pt was able to walk 258 m
Findings: Pt was able to do the test without any problems
12-minute Walk Test
Pt was able to walk 336 m
Findings: Pt felt fatigue and difficulty in breathing after walking 932