The Concept Of Clinical Case Presentation Assignment

The Concept Of Clinical Case Presentation Assignment

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Clinical Case Report
Learning Objectives
Define a clinical case presentation
List the typical information included in a clinical case presentation
Describe the usual format and organization of a clinical case presentation
Discuss the use of critical thinking and communication skills to successfully present a patient case
What is a Clinical Case Presentation?
A clinical case presentation is a demonstration of a learner’s knowledge and skills related to the management of disease states and drug therapies through application to an actual patient case. This assignment aims to incorporate subjective and objective findings to formulate an evidence-based plan using a previously identified disease process. Use a discussion from this course where you completed a SOAP Note of a disease process to prepare a clinical case report and presentation The Concept Of Clinical Case Presentation Assignment.

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The following should be included in your Clinical Case Report:
Patient Information
Disease State and Management Summary
Assessment
Plan of Care
Patient’s Treatment Course and Outcome(s)
Clinical Guidelines and Research
Case Summary

Learning Objectives

Thus, the goals of this clinical case report are as follows: to define the concept of clinical case presentation, to identify the common content of such presentation, to characterize its structure and format, and to discuss the thinking and interpersonal skills required for effective presentation of the patient case. This assignment aims to showcase the learner’s practical understanding and competency of disease management and drug therapies by solving a real-life patient case.

Introduction

Therefore, a clinical case presentation is a formal and orderly approach to presenting a patient’s medical details, health condition, management, and outcome. It combines both the subjective and the objective data to come up with a treatment plan. For this report, one will need to revisit a previous discussion in the course in which a SOAP note on a disease process was done to develop a clinical case report and presentation The Concept Of Clinical Case Presentation Assignment.

Patient Information

The patient in this case is J. D., a fifty-four-year-old female with a track record of asthma symptoms that was discovered at age 20. She also experiences sick, aura-free headaches and migraines that lack warning signs and are not preceded by an aura. She continues to have her symptoms even after using her albuterol inhaler, which was initially helpful to her; this means that her treatment plan needs to be changed. She currently requires an albuterol inhaler for acute use, Advair 250/50 mcg twice a day for controller use in asthma, and propranolol for migraines.

Disease State and Management Summary

Asthma is a lasting condition that leads to recurring instances of wheezing, difficulty respiration, tightness in the chest, and coughing, particularly at night or in the early morning

(Sahrun et al., 2024). These episodes are related to blockage of airflow in the lungs, which can be improved spontaneously or with treatment. Managing asthma requires attention to prevent worsening symptoms and maintain a quality of life. Effective care involves using medications and other strategies customized to meet each patient’s needs (Johnson et al., 2021)The Concept Of Clinical Case Presentation Assignment. J.D.s treatment plan has been modified due to her worsening symptoms; it now includes an albuterol inhaler for attacks and Advair 250/50 mcg twice daily for ongoing maintenance. This adjustment is crucial for symptom control. To avoid further deterioration.

Assessment

J.D. She has been diagnosed with an aggravation of asthma marked by increased wheezing, breathlessness, and nighttime coughing that have lasted for three days without improvement with her current albuterol inhaler. Upon examination, J.D. Exhibited wheezing during expiration, heightened effort, and a prolonged exhalation phase. Her oxygen saturation level was found to be at 92% indicating oxygen levels in the blood (hypoxemia). Given her history of asthma and the lack of response to her rescue inhaler, an acute exacerbation is suspected. Other potential diagnoses, such as COPD, viral respiratory infections, or heart failure, were considered.

However, J.D.s medical background and symptoms strongly point toward an asthma flare-up. Based on her history and symptoms, it seems that her current inhaler isn’t effectively controlling her asthma.

 Plan of Care

1. D.’s asthma care plan entails altering the medication schedule to tackle inflammation and prevent spasms of the bronchioles. Fluticasone/salmeterol has been escalated to 500/50 mcg a day. She has started using prednisone at a dose of 50 mg a day. About treatment, she has an inhaler which is Albuterol, for the management of symptoms. Apart from the medication, she requires teaching on the various ways to prevent asthma triggers and how to operate an inhaler. Specific goals on how to change her medications, when to get help, and signs that suggest worsening of her condition have been developed for her asthma. These are follow-up appointments scheduled to assess her condition and respond to changes made to the treatment plan. If the condition does not improve or gets worse, further adjustments may be necessary, including referral to a chest consultant The Concept Of Clinical Case Presentation Assignment.

Patient’s Treatment Course and Outcome(s)

It was necessary to change the treatment process for J. D.’s asthma when her symptoms became worse at the beginning. The increase of the medication dosage and initiation of corticosteroids were done to counter the worsening. In the follow up visit, the major aspect that will be examined is how she copes with the new treatment plan and if there is any progress or complications. Such changes are expected to improve her clinical status, her health-related quality of life, and the frequency and severity of relapses.

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Clinical Guidelines and Research

Current asthma management in the settings implies a certain approach depending on its severity. ICS is generally the preferred choice for use in the prevention and reduction of inflammation in long-term management. LABAs are often added to ICS therapy to improve asthma severity and stability of the disease. SABAs, known as acting beta-agonists, are used for relief during acute episodes and provide a fast action by widening the bronchial tubes. Oral steroids are used to exacerbate inflammation as soon as possible.

Guidelines stress the importance of intervention during exacerbations, follow-ups, and patient education. Intensive care entails using a rescue inhaler and oral corticosteroids if needed. Lung function monitoring entails using peak flow meters, patient education entails triggers, using inhalers, and signs of worsening of the condition (Talbot et al., 2024). Education of the patients enables the people to take charge of their health and recognize the symptoms of worsening of the condition (Nurek et al., 2021)The Concept Of Clinical Case Presentation Assignment. Some of the barriers to asthma control are patients’ nonadherence to prescribed therapies, improper technique of inhaler use, and underestimation of asthma severity. Healthcare providers are thus faced with these challenges that they must overcome through reminding patients and offering assistance.

Case Summary

1. D. is a 54-year-old female who has asthma and migraines, and the patient had worsened her symptoms for three days. Following an evaluation, it was concluded that she had an asthma flare based on her history and clinical findings. The management plan involved changing the client’s dosage, educating her on the triggers and proper use of inhalers, and a review appointment. This means the patients should be identified early and appropriate management initiated to avoid complications and hospitalization. The specific approach to managing J. D.’s case was developed to help her become healthy and improve her quality of life.

Conclusion

Therefore, asthma management requires medications and other therapeutic interventions based on the patient’s characteristics (Cote et al., 2020). Asthma flare-ups are controlled by education, timely checkup checks, and individualized care plans for the patient’s outcome (Qazi et al., 2021)The Concept Of Clinical Case Presentation Assignment. Thus, by making changes according to the guidelines but at the same time following the patient’s specific requirements, the quality of life of a person with asthma can be significantly improved. Therefore, the case of J. D. underlines the need to adopt individualized approaches to managing asthma while emphasizing the need for treatment to remain contingent on the patient’s changing health status.

References

Côté, A., Godbout, K., & Boulet, L. P. (2020). The management of severe asthma in 2020. Biochemical pharmacology, 179, 114112. https://www.sciencedirect.com/science/article/pii/S0006295220303488

Johnson, K. B., Wei, W. Q., Weeraratne, D., Frisse, M. E., Misulis, K., Rhee, K., … & Snowdon, J. L. (2021). Precision medicine, AI, and the future of personalized health care. Clinical and translational science, 14(1), 86-93. https://ascpt.onlinelibrary.wiley.com/doi/abs/10.1111/cts.12884

Nurek, M., Rayner, C., Freyer, A., Taylor, S., Järte, L., MacDermott, N., & Delaney, B. C. (2021). Recommendations for the recognition, diagnosis, and management of long COVID: a Delphi study. British Journal of General Practice, 71(712), e815-e825. https://bjgp.org/content/71/712/e815?onwardjourney=584162_v1

Qazi, A., Saba, M., Armour, C., & Saini, B. (2021). Perspectives of pharmacists about collaborative asthma care model in primary care. Research in Social and Administrative Pharmacy, 17(2), 388-397. https://www.sciencedirect.com/science/article/pii/S1551741119311234

Sahrun, S., Auliya, K., & Sulyastuty, K. (2024). A Case Report of Bronchial Asthma in a 56-Year-Old Mother With the Main Complaint of Shortness of Breath in the Emergency Room. Jurnal EduHealth, 15(01), 784-792. https://ejournal.seaninstitute.or.id/index.php/healt/article/view/4302

Talbot, T., Roe, T., & Dushianthan, A. (2024). Management of acute life-threatening asthma exacerbations in the intensive care unit. Applied Sciences, 14(2), 693. https://www.mdpi.com/2076-3417/14/2/693 The Concept Of Clinical Case Presentation Assignment

Clinical Guidelines/Research on Asthma Exacerbation in Adults
Asthma is a chronic disease characterized by airway inflammation and attacks accompanied by wheezing, shortness of breath, chest stiffness, and coughing. Asthma attacks or episodes increase these symptoms and cause a decline in the lung’s capacity to function, which needs appropriate treatment (Wagh et al., 2022). In primary care, awareness of asthma exacerbation management across the adult age span is essential in enhancing results and clients’ living standards. Such factors may include allergens, infections, pollution, and stress, leading to exacerbations. Asthma patients in this age group may have other coexisting conditions, such as cardiovascular diseases. Normal aging also affects the lungs and how the body reacts to medications; hence, treatment should be personalized.
They include the overall management of asthma from the onset to the identification and management of the worsening of the disease. This includes follow-up, patient awareness, and compliance with the recommended treatment regimens. The current clinical practices include a stepwise approach based on the severity of the diseases, as suggested by evidence-based practices. These guidelines include ICS as first-line therapy to reduce inflammation, LABAs added to ICS for better control, SABAs to relieve acute symptoms, and oral steroids for severe exacerbations.
Regarding the exacerbations, the guidelines highlight the importance of early management, frequent follow-up, and patient counseling. The strategies that fall under the early intervention include administering rescue inhalers and oral corticosteroids if required. Lung function monitoring is done through tools like peak flow meters, while patient education involves triggers, inhaler use, and early signs of exacerbation. Patient education is a key component, empowering patients to take control of their condition and recognize early signs of exacerbation. The most frequent issues in asthma control are patients’ compliance, improper use of inhalers, and underestimated disease severity. The task is made more challenging by environmental aspects and other coexisting conditions. Primary care providers can only overcome these challenges by constantly reinforcing patients’ knowledge and encouragement.
Some measures that can be taken to promote health among asthmatic patients include managing triggers, changing lifestyle, immunizations, and follow-up checkups. Maintenance means avoiding factors known to cause the condition, such as allergens and other pollutants. Preventive measures are exercising, quitting smoking, and maintaining a proper diet. It is crucial to ensure patients get vaccinated for the flu and pneumonia to avoid flu and pneumonia cases. Follow-up visits are essential in reviewing asthma status and management changes.
Hence, the treatment of exacerbations is based on pharmacological and non-pharmacological measures. Pharmacologically, it is necessary to change the dosage of the medications prescribed according to the current norms (ADA, 2020)The Concept Of Clinical Case Presentation Assignment. Apart from pharmacological treatment, patient counseling about the proper usage of inhalers, compliance, and avoidance of triggers is highly effective in preventing exacerbations. The main points to remember in asthma management are individualized patient care, continuous patient enlightenment, and prevention. It is important to develop management plans according to the specific patient and their life cycle. Continued education on medication usage, triggers, and self-observation can improve results substantially. Exacerbations should be promptly diagnosed and treated to avoid adverse effects and hospital admissions.
Asthma exacerbation is one of the crucial issues in primary care, and it should be managed systematically and patient-specifically. Therefore, by adhering to such guidelines, responding to healthcare issues, and advocating for health interventions, PCPs can enhance the QOL of asthma patients throughout their adult lives.
Case Summary: Asthma Exacerbation in a 54-Year-Old Female (J.D.)
J. D., a female 54-year-old patient with a history of asthma and headaches, has come with the worsening of her asthma symptoms, such as wheezing, shortness of breath, and nocturnal cough for three days. She has an albuterol inhaler, Advair 250/50 mcg, twice daily, and propranolol for migraines. Later, she was prescribed fluticasone/salmeterol 250/50mcg twice daily, and she took a five-day prednisolone burst, 50mg per day. Specifically, J. D. denies fever, chills, pain, changes in appetite, and weight changes, which suggests the requirement for assistance with coping strategies.
The most likely diagnosis is acute asthma, based on J. D.’s history of asthma, symptoms, and respiratory status at this time: oxygen saturation at 92%, expiratory wheezing, and increased respiratory rate. Management involves reviewing medications to increase their doses, counseling the patient regarding the appropriate use of the inhaler and ways of avoiding triggers, and a review appointment within seven days.
For healthcare providers, here are some key take-home messages: medication compliance, identifying features of relapse, and a holistic approach to management (Holland et al., 2020)The Concept Of Clinical Case Presentation Assignment. It is, therefore, important to remind patients about the correct use of inhalers and compliance with the medications prescribed for asthma. An effective management strategy incorporating medicinal and non-medicinal approaches based on patients’ specific characteristics may be highly beneficial.

References
American Diabetes Association. (2020). 9. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes—2020. Diabetes care, 43(Supplement_1), S98-S110. https://diabetesjournals.org/care/article-abstract/43/Supplement_1/S98/30822
Holland, T. J., Penm, J., Johnson, J., Sarantou, M., & Chaar, B. B. (2020). Stakeholders’ perceptions of factors influencing the use of take-home-naloxone. Pharmacy, 8(4), 232. https://www.mdpi.com/2226-4787/8/4/232
Wagh, M. R. D., Khade, M. P., & Ld, H. (2022). Asthma: A comprehensive outlook. International Journal for Research in Applied Science and Engineering Technology, 10(1), 691-698. https://www.academia.edu/download/78967095/Asthma_A_Comprehensive_Outlook.pdf The Concept Of Clinical Case Presentation Assignment

Case Summary

J.D. is a 54-year-old female client with a history of asthma diagnosed at the age of 20 and also has had Migraines without aura. She presents with increased wheezing, shortness of breath, and nocturnal cough, which suggest worsening asthma for the last three days. She has been using her albuterol inhaler, which she initially reported was effective in managing her symptoms but currently provides limited relief of features. Her current medications include an albuterol inhaler as needed for asthma exacerbations and Advair 250/50mcg twice daily for asthma maintenance. She also uses propranolol for migraines, and her fluticasone/Salmeterol has been increased to 500/50mcg twice daily with oral corticosteroids (prednisone) and 50mg orally for five days. However, she denies constitutional features such as fever, chills, pain, changes in appetite, and weight gain/loss. Other than asthma and her migraines, she denies other health concerns and indicates the need for support to enhance her coping measures.

Differential Diagnoses

Asthma exacerbation: Given that J.D. has had asthma for a very long time and has been on follow-up care, acute asthma exacerbations are a likely diagnosis that should be evaluated. The condition occurs due to hyperresponsiveness, bronchospasms, mucus spasms, and decreased airway patency (Levy et al., 2023)The Concept Of Clinical Case Presentation Assignment. Therefore, the client presents with features of decreased airway patency, including wheezing, shortness of breath, and cough. The presence of these features in the client’s case suggests asthma exacerbation is the most likely diagnosis for this case.

Chronic Obstructive Pulmonary Disease (COPD): This condition presents with similar manifestations, resulting in decreased airway compliance and restricted gaseous exchange. It occurs due to chronic irritation of the airway following exposure to noxious agents such as cigarette smoke (McCance & Huether, 2019)The Concept Of Clinical Case Presentation Assignment. Although the client does not have a history of cigarette smoke, COPD should be evaluated due to increased shortness of breath and wheezing.

Viral Respiratory Infections: Viral infectious agents also trigger inflammatory responses, resulting in airway problems. The client has had wheezing and non-responsive asthma shortness of breath for the past three days. These infectious agents are known to provoke the airway, resulting in acute manifestations of asthma exacerbations (National Heart, Lung, and Blood Institute, 2020).

Heart Failure: Heart failure occurs when the heart cannot pump blood to achieve adequate peripheral perfusion and venous return. This process results in fluid accumulation in tissues such as the lungs, resulting in pulmonary manifestations such as wheezing, chest discomfort, and dyspnea that exacerbate with slight activity (McCance & Huether, 2019)The Concept Of Clinical Case Presentation Assignment. Despite the absence of some of these manifestations, heart failure should be considered to help identify or rule out cardiovascular causes.

The Definitive/Most Likely Diagnosis

Ms. J. D.’s most probable diagnosis is an asthma exacerbation (flare) due to the described symptoms, history of asthma, and use of the rescue inhaler. Pathophysiologically, asthma exacerbation occurs due to airway inflammation, broncho constrictions, and increased mucus secretion, resulting in airway obstruction. Self-rating by Ms. J. D. Has complained of shortness of breath, wheezing, and coughing that increased at night over the last three days with the albuterol inhaler not as effective as it used to be rarely used. During the physical examination, the patient had expiratory wheezes on both sides, increased respiratory effort, and a prolonged expiratory cycle, which indicates respiratory distress (Holst et al., 2023). On the vital signs assessment, the patient’s oxygen saturation is 92%, which indicates hypoxemia. Diagnostic actions encompass the peak flow measurement and spirometry to measure the degree of obstruction during treatment and evaluate effectiveness or outcomes The Concept Of Clinical Case Presentation Assignment.

Asthma Management Guidelines

J.D.’s current stage is moderate persistent asthma that requires a combination of inhaled corticosteroids, long-acting beta-agonists, short-acting beta-agonists for quick relief, and a short course of oral corticosteroids (Holst et al., 2023).  According to the current clinical practice guidelines for managing an asthma exacerbation, the following changes would be made to Ms. J. D.’s current treatment plan: increasing her fluticasone/salmeterol dosing to 500/50 mcg twice daily and beginning a five-day course of oral steroids with prednisone, 50 mg per day. Further use of her albuterol inhaler PRN for irregular, intermittent use is recommended. The asthma education phase includes teaching the patient about trigger factors and the need to avoid them, proper inhaler usage, and ensuring that she follows her asthma management plan (Global Initiative for Asthma, 2023). A one-week follow-up is vital as it involves reassessment of symptoms and a response to treatment with spirometry if symptoms persist. If follow-up evaluation indicates non-improvement or worsening disease state, the nurse practitioner should consider referring the pulmonologist to establish a further course of action The Concept Of Clinical Case Presentation Assignment.

References

Global Initiative for Asthma. (2023). Global Initiative for Asthma – GINA. Global Initiative for Asthma – GINA. https://ginasthma.org/

Holst, S. S., Sabedin, E., Sabedin, E., & Vermehren, C. (2023). A shift in asthma treatment according to new guidelines: An evaluation of asthma patients’ attitudes towards treatment change. International Journal of Environmental Research and Public Health, 20(4), 3453.

Levy, M. L., Bacharier, L. B., Bateman, E., Boulet, L.-P., Brightling, C., Buhl, R., Brusselle, G., Cruz, A. A., Drazen, J. M., Duijts, L., Fleming, L., Inoue, H., Ko, F. W. S., Krishnan, J. A., Mortimer, K., Pitrez, P. M., Sheikh, A., Yorgancıoğlu, A., & Reddel, H. K. (2023). Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) update. NPJ Primary Care Respiratory Medicine, 33(1), 7. https://doi.org/10.1038/s41533-023-00330-1

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McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.

National Heart, Lung, and Blood Institute. (2020). 2020 Focused Updates to the Asthma Management Guidelines | NHLBI, NIH. Www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates The Concept Of Clinical Case Presentation Assignment