CASE STUDY 2- Week 5• What additional questions will you ask? Do you have any other symptoms other than the cough? Any shortness of breath? Are you coughing up any mucous? Have you had any fever?-Did the case addressed the LOCATES mnemonic? If not, what else will you ask? Do you have any pain? Any associated symptoms? Is there anything that helps with your cough or makesit worse?- What additional history will you need? (Think FMH, allergies, meds, histories)Any additional medical history would be helpful as well as known allergies and current med list. If the patient is not sure what medication he ran out of, the pharmacy could be contacted or that information could easily be found in the patient’s record depending on what clinical setting you are working in. - What additional examinations if any will you conduct?Vital signs would need to be obtained, oxygen saturation along with auscultation of the heart and lungs. - What additional diagnostic tests if any will you conduct?Additional diagnostic testing may include a chest x-ray if symptoms persist. • List 3 differential diagnoses? • What is your most likely primary diagnosis and rational?The patient’s physical exam is relatively unremarkable other than the patient’s prolonged expiration and his expiratory wheezing. His subjective history reveals increased cough and shortness of breath—these findings combined would lead me towards an asthma exacerbation (Burns et al., 2017). Asthma exacerbations are often the result of environmental triggers such as pollen, dust, pet dander, and (as is likely the case for Brian) tobacco smoke—either directly or via secondhand smoke. Additional causes include concurrent respiratory infections, cold and/or dry air, acid reflux, hormones, medications, and stress (Mayo Clinic, 2018). Brian’s exacerbation may also be precipitated by running out of his long acting corticosteroid inhaler. These medications will help prevent an asthma exacerbation, or an acute asthma “attack”. Asthma attacks, or worsening asthma symptoms, can vary in intensity and symptoms, ranging from mild to severe, sometimes even life threatening (Cushny, 2013). You should seek emergency medical
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- Summer '18
- Asthma Case Study