Your patient is a 23-year-old female. She presents with coughing and wheezing which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her last prenatal visit was one month ago in another state. She has an appointment with the prenatal care provider next week, however her respiratory symptoms brought her to your office today.

History – Chickenpox as a child. Asthma as a child, diagnosed at age 8 for which she used a SABA when needed. She has not had the need to use an inhaler since she was 19. She takes only her prenatal vitamin. No other acute or chronic problems. She advises you that she is up to date on all immunizations except she has not had a flu shot (it is October).
Social – Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance.

HPA – Non-productive cough x 3 weeks. Wheezing audible from across the room. She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints.

PE/ROS – Pt appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular. The remainder of the exam is WNL.

02 98% and FEV 70%

Directions:

1. Diagnose the patient based on the above findings and provide your rationale for how you arrived at the diagnosis.
2. Develop a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
3. Describe community resources (using your own community) currently available in your state/city to support this patient.
4. Provide a communication plan that you will use to ensure the patient is an active participant in the treatment plan. Refer to therapeutic communication concepts.

ANSWER

Diagnosis and Rationale

The patient presents with a non-productive cough and wheezing that has persisted for three weeks. Given her medical history, particularly her past diagnosis of asthma, it is likely that she is experiencing an asthma exacerbation during her pregnancy. The exacerbation is characterized by the presence of wheezing, which is audible from a distance, as well as fatigue and nighttime awakenings. Her past use of a short-acting beta-agonist (SABA) inhaler for asthma suggests a pre-existing history of asthma. During pregnancy, hormonal changes and the increased demand on the respiratory system can exacerbate asthma symptoms, making pregnant women with asthma more susceptible to respiratory issues. Her FEV1 of 70% suggests airflow obstruction, which is common in asthma exacerbations.

Treatment Plan

Pharmacologic

1. Short-Acting Beta-Agonist (SABA): The patient should resume the use of her SABA inhaler (e.g., albuterol) for acute relief of wheezing and shortness of breath. She should be educated on proper inhaler technique to maximize drug delivery.

2. Inhaled Corticosteroid (ICS): Consider initiating low-dose ICS therapy (e.g., budesonide) as maintenance therapy to control her asthma symptoms during pregnancy. ICS is considered safe during pregnancy and is effective in preventing exacerbations.

Non-Pharmacologic

1. Environmental Modifications:Advise the patient to identify and avoid potential asthma triggers in her new living environment, such as allergens or irritants like tobacco smoke.

2. Asthma Action Plan:Develop a personalized asthma action plan in collaboration with the patient, specifying when and how to use her rescue inhaler and when to seek medical attention.

3. Patient Education: Provide comprehensive education on asthma management during pregnancy, including the importance of medication adherence, recognizing worsening symptoms, and the role of peak flow monitoring.

Community Resources

In our community, there are several resources available to support this patient:

1. Local Health Clinics: Many community health clinics provide low-cost or sliding-scale fee services, including prenatal care and asthma management. These clinics can help the patient access prenatal care and receive regular check-ups for her asthma.

2. Women, Infants, and Children (WIC) Program: This federal program offers nutrition education, healthy food, and support to low-income pregnant women and mothers with young children. The patient can benefit from nutritional guidance and assistance.

3. Emergency Medicaid: Given the patient’s lack of medical insurance, she may qualify for Emergency Medicaid, which provides coverage for emergent medical conditions. It is crucial to assist her in exploring her eligibility for this program.

4. Domestic Violence Support Services: As the patient has relocated to escape domestic abuse, local domestic violence support organizations can provide counseling, shelter, and legal assistance to ensure her safety and well-being.

Communication Plan

Establishing effective communication with the patient is vital to ensure her active participation in the treatment plan. Utilize therapeutic communication concepts such as active listening, empathy, and shared decision-making:

1. Active Listening: Begin each interaction by actively listening to the patient’s concerns, fears, and questions. Encourage her to express herself freely.

2. Empathy: Acknowledge the challenges she is facing, including her recent relocation and lack of support network. Express empathy and understanding regarding her situation.

3. Patient Education: Provide clear and understandable information about asthma, its management during pregnancy, and the importance of prescribed medications. Use visual aids and written materials to enhance comprehension.

4. Shared Decision-Making: Involve the patient in developing her asthma action plan, allowing her to voice preferences and concerns. Ensure she understands when and how to use her inhalers.

5. Regular Follow-Up: Schedule regular follow-up appointments to monitor her asthma control, assess medication adherence, and address any issues or questions. Encourage open communication during these visits.

In conclusion, the patient’s diagnosis of an asthma exacerbation during pregnancy necessitates a multifaceted treatment plan that includes pharmacologic and non-pharmacologic interventions. Leveraging community resources is essential to support her in accessing healthcare and addressing her social needs. Effective communication, characterized by active listening and empathy, will empower the patient to actively engage in her treatment plan, ultimately improving her health outcomes during this critical period of her life.