NURS 6541: Primary Care of Adolescent and Children Week 5 Discussion Case Study Two Diagnosis and Management of Respiratory, Cardiovascular, and Genetic Disorders HPI: Brian is a 14-year-old known asthmatic with a 2-day history of worsening cough and shortness of breath. He reports using his albuterol inhaler every 3-4 hours over the previous 24 hours. He has a long-acting inhaled corticosteroid. He can’t recall which one. He said he ran out a few weeks ago and has not had time to obtain a refill. He denies cigarette smoking, but his clothing smells like smoke. PE: Patient is sitting by himself. His parents are in the room during the visit. No purse lip breathing noted. Occasional nonproductive coughing during the interview. PULM: You note prolonged expiration and expiratory wheezes in all lung fields. There are no signs of dyspnea. Additional questions from LOCATES It is crucial to ask the patient if there any other symptoms he is experiencing aside from the cough, such as fever or vomiting. He should also be asked if there is anything that makes the cough worse or better? He should be asked if the cough is worst during the day or at night? Also, there is a need to ask if the cough is productive or non-productive. In terms of history, the
patient should be asked about past medical history, history of allergies and current medication list. Since the patient states he ran out of his long-acting corticosteroid medication and does not know the name of the medication it is vital to contact the pharmacy to inquire about the medication he is on and also check-in his medical record before proceeding with treatment plan. Additional examinations to conduct will be taking the child’s oxygen saturation and measuring his peak flow level. In addition to auscultation of heart and lung sounds, It is essential to obtain the patient's vital signs by checking to see if there are tachycardia and rapid pulse. A diagnostic test o include will be to order a chest X-ray due to his presentation of asthma exacerbation in addition to the presence of secondhand smoke exposure.
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