A3.3.1HowOxygenCells - HBS



Activity 3.3.2: Medical History – Visit #3Patient’s Name:Age:Date:Melissa Martin11February 25 Height:Weight:Temperature:52 inches71 lbs.98.9°FBlood Pressure:Pulse:Respiration Rate:106/6868 bpm20 bpmCase HistoryAt this appointment Melissa appears a bit run down, but she is in good spirits. She reports that one day at school this week she started to wheeze during gym class. As she became more self-conscious about it, she started to feel tightness in her chest and the wheezing intensified. She used the inhaler that was provided to her and felt almost immediate improvement. She says that within a few minutes, she was able to breathe easier and the wheezing got better. She took it easy the rest of the day, and she has not had an incident of that nature since. She does report that she feels like she is, however, getting a cold and reports a low grade headache.Physical ExamPatient’s pulse is normal. Pulse ox – 90%Slight wheezing is appreciated. Lungs are clear.Patient said she has no ear pain or a sore throat. Upon inspection, her ears are clear; however, her nasal passageways are slightly inflamed and irritated.Patient’s glands are not swollen.Patient’s speech, hearing, and vision appear normal.Clinical Test ResultsSpirometry was completed at this visit. Results indicate an average total lung capacity. However, FEV1 was measured as 79%. After administration of albuterol, a short-acting bronchodilator, FEV1 was measured again at 93%. This response indicates that the impairment is reversible. Diagnosis/Follow UpMedicationsMelissa was provided prescriptions for both a short term “rescue” medication as well as a long term control medication. Copies of the prescriptions are included below. Zafirlukast is a type of medicine called a leukotriene receptor antagonist. It works by blocking the action of leukotrienes, which are chemicals released by the body as part of the inflammation response. In the lungs Leukotrienes act in two ways, causing the airways to narrow. They cause the muscles lining the airways to contract, thereby making the airways narrower. They also cause inflammation of the lining of the airways, which results in increased mucus production and further narrowing of the airways. By blocking the actions of leukotrienes, zafirlukast prevents the increased mucus production, inflammation and narrowing of the airways that occurs in asthma. This helps prevent asthma attacks, but doesn’t treat them.Albuterol is used to prevent and treat wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease. Albuterol inhalation aerosol is also used to prevent breathing difficulties during exercise. Albuterol is in a class of medications called bronchodilators. It works by relaxing and opening air passages to the lungs to make breathing easier.Zafirlukast can cause nausea, loss of appetite, pain in the right upper part of your stomach, excessive tiredness, lack of energy, itching, yellowing of the skin or eyes, flu-like symptoms, rash, swelling of the eyes, face, lips, tongue, or throat, difficulty breathing or swallowing, hoarseness, pain, burning, numbness, or tingling in the hands or feet. Albuterol can cause uncontrollable shaking of a part of the body, nervousness, headache, nausea, vomiting, cough, throat irritation, muscle, bone, or back pain, fast, pounding, or irregular heartbeat, chest pain, rash, hives, itching, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, increased difficulty breathing, difficulty swallowing, hoarseness lefttop PLTW Medicine3939 Priority Way South DriveIndianapolis, IN 46240-476252057400Name: Melissa Martin-476252254250Date of Birth: 5/6/03-476252254250Address: 1415 Anytown Road-476252260600Date: 2/25/15? ControlAccolate 10mg tab60Sig 10mg PO bid pcZafirlukast: By mouth, twice a day, after meals 16926891574X00XGeneric Substitution Allowed 116840011049000Dispense as Written8565601416050STPSignature of PrescriberRefill 0 1 2 3-571522860PLTW Medicine3939 Priority Way South DriveIndianapolis, IN 46240-476252057400Name: Melissa Martin-476252254250Date of Birth: 5/6/03-476252254250Address: 1415 Anytown Road-476252260600Date: 2/25/15? RescueAlbuterol sulfate 1.25mg/3mlSig 1-2 inhalations q4-6h PRN; 2 inhalations before exerciseAlbuterol Inhalation: every 4-6 hours as needed. 16926891574X00XGeneric Substitution Allowed 116840011049000Dispense as Written8565601416050STPSignature of PrescriberRefill 0 1 2 3 ................
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