Ms. E is a 17-year-old Hispanic female who presents with SOB (shortness of breath) tight chest, cough, wheezing, and general malaise. She states that she was up most of the night with trouble breathing and has lost her inhaler. She also would like a medical clearance to return to school.
Brief history: Lives with mother, one sister age 14, and stepfather. Father unknown. Allergies: Seasonal rhinitis. Smokes two to three cigarettes per day and half a pack on weekends for three years. Drinks on occasion two bottles of beer or wine coolers. Today she ate soda and pizza for breakfast. Grades: Repeating Junior year receiving B’s, C’s and one D.
PMH: Asthma since age 8
Medications: Albuterol HFA 1-2 puffs every 4-6 hours as needed.
Medrol dose pack two years ago
FH: Mother with COPD
- Describe your actions. What is the first thing you would do?
- Once stabilized, what additional subjective history would be pertinent to this adolescent student?
- What areas of the objective assessment are appropriate?
You conduct a Physical Exam: HGT: 64” WGT: 100 lbs. T: 99.9 BP: 118/60 HEENT: erythematous posterior pharynx, enlarged submandibular nodes and wheezes throughout lung fields.
- Develop a problem list for this patient. What is the differential diagnosis for SOB? Based on the information provided, what are the most likely acute diagnoses for this case?
- Develop a plan of care for this client that addresses both immediate and ongoing care.
- What areas of health promotion would you discuss with her?
- Discuss the implications of poorly controlled asthma on adolescent well-being.
- What are some emerging and/or complimentary therapies for treatment resistant asthma?
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