A3.3.1HowOxygenCells



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 UpHer diagnosis is asthma. The test results of her FEV1 indicated a significant improvement in breathing after being given a single dosage of Albuterol, a rescue inhaler for people with asthma. Now, the specific type of Asthma is physically induced asthma. Just before you exercise, take 1-2 puffs of the rescue inhaler. The details of how much and when are below in the medications tab.MedicationsCONTROL-Accolate- Take a 10 milligram tablet by mouth twice a day after meals. This medicine prevents symptoms and helps decrease the # of asthma attacks. It makes breathing easier for you by blocking natural things in your body that may cause or worsen asthma.Side Effects: headache, sore throat, trouble sleepingRare Symptoms: mental mood changes, worsening shortness of breath, tingling hands and feet, joint aches, coughing up blood, swelling hands and feet, chest pain, easy bruising, infection, liver problemsIf you are turning a yellow color(jaundice), seek medical attention because it could be liver disease which can be potentially fatal. If breathing becomes more difficult, alert your doctor so he can change dosage or take you off. If you experience mood changes or suicidal thought or actions, immedietley see a doctor to take you off the medication.RESCUE-Albuterol- Take 1-2 inhalations of 1.25/3ml dosage everyday as needed before physical activity.Albuterol is your rescue inhaler, not your asthma control medication. This is an as needed med not a long term use one. This will help prevent an asthma attack from occurring while you exercise.Side effects(rare)- Abdominal heart rhythm, diabetes, epilepsy/seizure disorder, heart disease/congestive heart failure, overactive thyroid. Side effects-wheezing, chest pain, tight chest, pounding heart, tremor, nervousness, extremely high blood pressure.If you experience any of the rare side effects of this rescue inhaler, seek medical attention as soon as possible because these are life threatening. As for the normal side effects, if you are experiencing blood pressure that is abnormally high and causing confusion or disorientation, seek medical attention then as well. The other side effects are normal, but if they don’t get better over time go to the doctor so he can change the dosage of medication or take you off of it.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? Accolate 10mg tab60Sig 10mg PO bid pc16926891574X00XGeneric 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? Albuterol sulfate 1.25mg/3mlSig 1-2 inhalations q4-6h PRN; 2 inhalations before exercise16926891574X00XGeneric Substitution Allowed 116840011049000Dispense as Written8565601416050STPSignature of PrescriberRefill 0 1 2 3 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download