NURS 504
CC:
“I think I am having problems with my asthma and I need a refill on my Proventil”
HPI:
FC is a 25 YO female who presents to primary care with increased shortness of breath,
wheezing, poor exercise tolerance. FC states she has daily symptoms and is “not able to
work out at the gym like she used to.”
PMH:
Asthma X 10 years and has had 4 asthma related ER visits in last year.
FH:
Mother with HTN; Father with COPD/Asthma.
SH:
Patient denies alcohol or tobacco; however, her roommate smokes and has a cat.
Allergies:
NKDA
Medication History:
Proventil HFA–2 puffs every 4–6 hours as needed
Ortho Evra–Apply 1 patch each week for 3 weeks followed by 1 week patch-free
MVI
Physical Exam:
Gen–A & O, with audible wheezing and dyspnea
VS –BP 135/75, P 100, RR 30, T 98.6, Ht. 5’3,” Wt. 75 kg
HEENT–PERRLA, EOMI
Neck–no adenopathy
Lungs–Diffuse wheezes bilaterally on exhalation
CV–Tachycardia, no MGR
Abd–non-tender, soft, + bowel sounds
Neuro–all cranial nerves intact
CXR: No infiltrates
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ASTHMA CASE STUDY
NURS 504
Lab Results:
Na 139 mEq/L
K 4.4 mEq/L
Cl 102 mEq/L
CO2 26 mEq/L
BUN 20 mg/dL
Scr 1.0 mg/dL
Historical Christian: Frances Jane Crosby (24 March, 1820– 12 February, 1915), known as Fanny Crosby,
was an
American Methodist rescue mission worker, poet, lyricist, and composer. During her lifetime, she was
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