Clinical Evaluation

C.C. F/U Hospitalization for asthma
HPI: 11 y.o. F went on camping trip with girl scout troop a couple of weeks ago. During this trip she went
hiking, camping and sat around the campfire during the evening. Initially, she noticed shortness of
breath and wheezing in the evening around the campfire. Unfortunately, symptoms continued during
the day where she was unable to catch her breath. Scout leader assisted her with the inhaler, ProAir.
The inhaler helped in the beginning, however as the trip continued, she had more attacks. It was
decided to have her mother pick her up and take her to the hospital. On arrival to hospital they found
her to be in acute respiratory distress. She was started on continuous nebulizer treatments, given
steroids and azithromycin. She was doing better and 2 days later she was discharged home. She is
following up in the office after hospitalization. Mother reports symptoms have been uncontrolled since
leaving the hospital. Using inhaler two times a day. She denies chest tightness or SOB. Does still have a
non-productive cough at times.
Allergies: Bactrim, Trimethoprim, Ceclor
Current Mediation: Pro Air 90mcg/spray MDI PRN bronchospasm. Mucinex 1-2 tab PO PRN bronchial
secretions. Medrol dose pack. Azithromycin x 2 more days, 500 mg PO daily.
PMH/SH: Asthma, never required intubation. Hospitalized four times for it.
Social History: Pt and family deny tobacco, illicit drugs or alcohol use.
Family History: Mother has hypertension and her father has DM. She is the only child and is unsure of
the history of her grandparents.
Review of Systems (ROS):
Constitutional symptoms- Patient denies fever, chills, loss of appetite, difficulty sleeping.
Eyes- Patient denies blurred vision, difficulty focusing. ENT- Patient denies ear pain, sore throat, nasal
congestion. Cardiovascular- Denies CP or SOB. Respiratory: Patient denies difficulty breathing, wheezing,
pain on inspiration Gastrointestinal- Patient denies dysphagia, reflux, nausea, vomiting, diarrhea,
constipation, hematemesis, abdominal or epigastric pain. Musculoskeletal- Patient denies joint pain,
swelling, muscle pain or cramps, neck pain or stiffness. Integumentary- Denies changes in skin, rash, or
bruising. Neurologic- Patient denies weakness, numbness. Psychiatric- Denies, mood changes, anxiety,
depression, nervousness, insomnia. Endocrine- Patient denies polydipsia, polyphagia, polyuria.
Allergic/immunologic- Patient denies seasonal allergies.
OBJECTIVE DATA (O):
Constitutional- VS: Temp- 99.1, BP- 104/72, HR- 89 Height- 5’0″, Weight- 82 lbs.; General Appearance:
11-year-old female, presents in no acute distress, alert and oriented x 3.
Eyes- sclera white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Ear, Nose, Throat- External
appearance normal- on otoscopic exam tympanic membranes clear. Hearing is intact.
Nose: Bilateral nasal turbinates’ slightly swollen patent. Septum is midline.
Mouth: pink, moist mucous membranes.
Throat: no inflammation or lesions present. Tonsils WNL. Cardiovascular- S1, S2. Regular rate and
rhythm, no murmurs, gallops, or rubs. Extremities: no cyanosis, clubbing, or edema, less than 2 second
refill noted. Respiratory- Clear bilaterally, no wheezing or rhonchi. Symmetrical chest rise, no use of
accessory muscles.
Gastrointestinal- abdomen soft and nontender to palpation, nondistended. Bowel sounds present in all
4 quadrants.
Musculoskeletal- Normal ROM, joint stability normal in all extremities, no tenderness to palpation.
Integument/lymphatic- Inspection: No scaling, redness or breaks on neck, or arms, or trunk. Skin warm,
dry and intact with good skin turgor. Neurologic- Grossly alert and oriented x3, communication ability
within normal limits. Psychiatric- Judgment and insight intact, rate of thoughts normal and logical.
Pleasant, calm, and cooperative. Lymph nodes not palpable.
Directions:
Please evaluate the subjective and objective information provided to you in the file below.
The first part of the discussion board is to identify all pertinent positive and negative information.
Would there be any other information you would want to obtain?
Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.
Be sure to include APA in-text citations and provide full reference citation at the end of the discussion.

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