This presentation was based on diagnosing a fictional patient, KB, here is the additional information from this particular presentation:
IAL Asthma Case
CC: “I need to refill my Ventolin”
KB is a 25-year-old female who presents to your community based asthma clinic for an evaluation. She reports, “My asthma has gotten so much worse since I’ve moved back up here. I’ve been waking up at night coughing and wheezing, plus I just can’t seem to get my errands done because I feel so out of breath for days after an attack”. Upon further questioning KB describes having symptoms of wheezing almost daily, with 2-3 exacerbations per week, along with a disrupted sleep pattern in which she wakes up about once a week with symptoms. KB brought a log of her peak flow readings from when she was in Miami, but she lost her PF meter during the move. Her personal best was estimated to be 485 L/min. She also states, “I’ve been going through my Ventolin like crazy, I really think I need another one”.
PMH: Asthma since childhood, diagnosed in 1992. Hospitalized once between 1992-1995, with several trips to the ER. Never been intubated.
Seasonal allergies (pollen, ragweed)
Sprained knee from high school basketball
Occasional migraines and heartburn, KB thinks stress related.
FH: Father: alive, 54, no known medical problems
Mother: alive, 52, has emphysema (45-pack-year history) and lupus
Sister: alive, 19, attends college and has no known medical problems
SH: Denies tobacco and illicit drugs. Occasional EtOH.
Has recently moved in to an older apartment near her mother who is ill.
Was previously living in Florida for 7 years, most recently Miami.
Works from home as a publicist, travels extensively.
Very active lifestyle, loves basketball and sailing.
Medications: Ventolin HFA MDI 2 puffs every 4 – 6 hours as needed
Flovent HFA 110 mcg 2 puffs twice daily (last filled in Miami 12/2009)
Loratidine 10 mg daily as needed for allergies
Ibuprofen 200 mg as needed for headache
Tums 2 tablets four times a day as needed for heartburn
Echinacea extract as needed for onset of colds/flu
Allergies: Aspirin, however has food allergies to peanuts (anaphylaxis) and she cannot eat dried fruit (wheezy)
ROS: + cough, + wheeze, + rhinitis
+ occasional heartburn, + occasional headache
PE: Gen: WNWD female in mild respiratory distress
VS: BP=112/70, P=70, RR=20, T=99o, Wt=120 lbs., Ht=62 in.
Lungs: Mild wheezing bilaterally
Labs: Not available
Assessment: Poorly controlled asthma