Asthma Case Study – 2 Pages

John is a 13 yr old male who presents to your clinic accompanied by his mother with complaint of productive cough, chest and nasal congestion and intermittent chills x 7 days. He reports symptoms initially started with mild nasal congestion, clear runny nose and sorethroat, but got worse the past few days. He now has chest congestion, productive cough with greenish-yellow sputum, chills, and mild headache x 2 days. OTC meds for cold have not helped. He denies any known sick contact.

Mother further reports she noticed John has been wheezing more the past 2 months. He used to use his albuterol inhaler about once a month but now uses it 3-4 times a week.  Both John and his mom reported nighttime dry cough and wheezing which occurs about 1-2 times a week

Past Medical History :  Asthma, Allergic rhinitis, Atopic dermatitis

Medication History :  Albuterol HFA prn, Zyrtec 10mg QD,  Tylenol 500mg -1tab prn for headache and chills.

Family Medical History :  Father: HTN;  Mom: healthy. 3 siblings-all healthy

Drug Allergy: NKDA

Social History :  Denies alcohol or cigarette use. Denies illicit drug use. Occupation:  Student.

Vaccination : Up to date

Physical Exam

Gen:  Slightly lethargic, otherwise in no acute distress

V/S: BP: 124/72, HR: 110, T: 101.3(oral), RR: 22, wt: 132lbs, Ht: 66inches

HEENT:  Nasal mucosa erythematous, mild nasal congestion, tonsils and pharynx normal, slight postnasal drainage, light green nasal discharge.

CV: Normal S1& S2, rhythm regular

Resp:  regular. Mild expiratory wheezing bilaterally to auscultation. No use of accessory muscles.  02 saturation: 95%

Abd: Soft, non-distended, non-tender, bowel sounds + and normal x 4 quadrants, no masses palpated.

Neuro/Psych: alert and oriented X 3. CN II-XII grossly intact.  Good eye contact, speech clear and goal oriented. Affect normal.

Skin: Normal, no lesions.

Diagnostic Tests:  In-house: CBC with diff and CXR

Labs/X-ray

L.C’s values

WBCs

12,000

Neutrophil

8,500

Lymphocyte

4,500

Platelet

190, 000

Hemoglobin

14

HCT

38%

CXR Result

Consolidation in left upper lobe

Case Questions:

1. What is/are the diagnoses: Support with literature evidence and interpretation of data presented in the case study.  Discuss the pathophysiology of the selected diagnosis.

2. Present and briefly discuss(rationale) 3 differential diagnoses for this patient.

3. Discuss plan of care for this patient-pharmacological, education, referral, and need for further diagnostic testing if any. Discuss thoughts about his asthma?.

3 References within the last 5 years