Case study: Part Two (graded)
Further questioning for Cathy: Uses < 1 albuterol inhaler/year. Has noticed chest feels a little tight upon waking, has had increased morning headaches and white thin nasal discharge. She denies sputum. No new allergy triggers noted. She denies heartburn.
PE: Height 5'5", Weight 148 pounds
VS : BP 130/72, T 98.0, P 62, R 16 Sao2 98%
General: 48-year-old Caucasian female appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless. Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.
HEENT: Head normocephalic. Hair thick and distribution even throughout scalp.
Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender
Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses nontender to palpation.
Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.
Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight wheezing noted on forced expiration.
CV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally
Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.
Labs:
PEF< 80%, FEV1/FVC >85%
Discussion Questions Part Two:
What is your primary diagnosis for Cathy given the symptoms, exam results, and history? Include the rationale and a reference for your diagnoses.
What is your first line treatment plan for Cathy including medications, labs, education, referrals, and follow-up?
1)http://www.slideshare.net/ashrafeladawy/spirometry-interpretation
2) http://asthmaready.org/static/posters/Sensitivity_FEV1_FEF75.pdf
3) http://patient.info/doctor/spirometry-calculator