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Activity 3.3.

2: Medical History Visit #3

Patients Name: Age: Date:


Melissa Martin 11 February 25
Height: Weight: Temperature:
52 inches 71 lbs. 98.9F
Blood Pressure: Pulse: Respiration Rate:
106/68 68 bpm 20 bpm

Case History
At 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 Exam
Patients 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.
Patients glands are not swollen.
Patients speech, hearing, and vision appear normal.

Clinical Test Results


Spirometry 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 Up (from Activity 3.3.2)


Melissas FEV1 shows that there is mild obstruction in her airways, which is
the main symptom of asthma. The inflammation in her nasal cavity is
visual proof of inflammation of Melissas airways. The improvement of the
bronchodilator shows that her asthma, if present, is mild and does not
constitute any medical emergency at this time. All signs show Melissa to be
asthmatic.

It is suggested that Melissa continues to use an inhaler and/or a

2014 Project Lead The Way, Inc.


Human Body Systems Activity 3.3.2 Medical History Visit #3 Page 1
bronchodilator as needed. Steroids may be used if conditions worsen and if
doctor prescribes it in a future visit. At this vulnerable time in Melissas
development of asthma, it is strongly suggested that she limit her time
outside (especially when it is cold or during the time of pollination) and
that she stay away from cigarette smoke.

Medications
Melissa 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.
Accolate tablets work by blocking chemicals produced by the body that
cause the lining of breathing passages to swell. Side effects may include
headache, diarrhea, stomach pain, weakness, dizziness, muscle pain, or
sore throat or cold symptoms. More serious side effects include worsening
asthma symptoms; trouble breathing, worsening cough, or fever; mood or
behavior changes such as depression, anxiety, or sleep problems; skin
problems such as rashes or bruising; muscle problems such as numbness,
weakness, or pain; nausea or upper stomach pain; or abnormal urine or
stools such as dark urine or clay-colored stools. If any of these serious side
effects occur, call your doctor immediately.

Albuterol sulfate is an inhaler that treats wheezing and shortness of breath


by opening breathing passages and relaxing muscles. Side effects may
include headache, dizziness, sleep problems, coughing, hoarseness, sore
throat, runny or stuffy nose, nausea, vomiting, dry mouth or throat, muscle
pain, or diarrhea. More serious side effects include bronchospasm,
nervousness, shaking, chest pain, irregular heartbeats, low potassium, or
dangerously high blood pressure. If you experience any of these serious
side effects, call your doctor immediately.

2014 Project Lead The Way, Inc.


Human Body Systems Activity 3.3.2 Medical History Visit #3 Page 2
CONTROL RESCUE
PLTW Medicine
PLTW Medicine
3939 Priority Way South Drive3939 Priority Way South Drive
Indianapolis, IN 46240 Indianapolis, IN 46240

Name: Melissa Martin Name: Melissa Martin


Date of Birth: 5/6/03 Date of Birth: 5/6/03
Address: 1415 Anytown Road
Address: 1415 Anytown Road
Date: 2/25/15 Date: 2/25/15


Accolate(generic name: Zafirlukast)
Albuterol sulfate (generic name
10mg tab given) 1.25mg/3ml
60 Sig 1-2 inhalations q4-6h PRN; 2
Sig 10mg PO bid pc inhalations before exercise
Take 1 tablet by mouth (PO)Take
twice
1-2
a inhalations every 4-6
day (bid) after meals (pc). hours as needed; take 2
inhalations before you exercise

Generic Substitution Allowed X Generic Substitution Allowed X

Dispense as Written Dispense as Written

STP STP
Signature of Prescriber Signature of Prescriber

Refill 0 1 2 3 Refill 0 1 2 3

2014 Project Lead The Way, Inc.


Human Body Systems Activity 3.3.2 Medical History Visit #3 Page 3