John is a 13 yr old male who presents to your clinic accompanied by his mother with complaint of productive cough, chest and nasal congestion and intermittent chills x 7 days. He reports symptoms initially started with mild nasal congestion, clear runny nose and sorethroat, but got worse the past few days. He now has chest congestion, productive cough with greenish-yellow sputum, chills, and mild headache x 2 days. OTC meds for cold have not helped. He denies any known sick contact.
Mother further reports she noticed John has been wheezing more the past 2 months. He used to use his albuterol inhaler about once a month but now uses it 3-4 times a week. Both John and his mom reported nighttime dry cough and wheezing which occurs about 1-2 times a week
Past Medical History: Asthma, Allergic rhinitis, Atopic dermatitis
Medication History: Albuterol HFA prn, Zyrtec 10mg QD, Tylenol 500mg -1tab prn for headache and chills.
Family Medical History: Father: HTN; Mom: healthy. 3 siblings-all healthy
Drug Allergy: NKDA
Social History: Denies alcohol or cigarette use. Denies illicit drug use. Occupation: Student.
Vaccination: Up to date
Gen: Slightly lethargic, otherwise in no acute distress
V/S: BP: 124/72, HR: 110, T: 101.3(oral), RR: 22, wt: 132lbs, Ht: 66inches
HEENT: Nasal mucosa erythematous, mild nasal congestion, tonsils and pharynx normal, slight postnasal drainage, light green nasal discharge.
CV: Normal S1& S2, rhythm regular
Resp: regular. Mild expiratory wheezing bilaterally to auscultation. No use of accessory muscles. 02 saturation: 95%
Abd: Soft, non-distended, non-tender, bowel sounds + and normal x 4 quadrants, no masses palpated.
Neuro/Psych: alert and oriented X 3. CN II-XII grossly intact. Good eye contact, speech clear and goal oriented. Affect normal.
Skin: Normal, no lesions.
Diagnostic Tests: In-house: CBC with diff and CXR
Consolidation in left upper lobe
1. What is/are the diagnoses: Support with literature evidence and interpretation of data presented in the case study. Discuss the pathophysiology of the selected diagnosis.
2. Present and briefly discuss(rationale) 3 differential diagnoses for this patient.
3. Discuss plan of care for this patient-pharmacological, education, referral, and need for further diagnostic testing if any. Your thoughts about his asthma?.
4. Support plan of care/intervention with literature evidence.