Question Answered step-by-step identify all pertinent positive and negative information. Would… identify all pertinent positive and negative information. Would there be any other information you would want to obtain? create differential diagnosis list with at least 3 possibly actual diagnosis based on your findings. create plan utilizing clinical practice guidelines for the priority diagnosis. C.C. F/U Hospitalization for asthma HPI: 11 y.o. F went on camping trip with girl scout troop a couple of weeks ago. During this trip she went hiking, camping and sat around the campfire during the evening. Initially, she noticed shortness of breath and wheezing in the evening around the campfire. Unfortunately, symptoms continued during the day where she was unable to catch her breath. Scout leader assisted her with the inhaler, ProAir. The inhaler helped in the beginning, however as the trip continued, she had more attacks. It was decided to have her mother pick her up and take her to the hospital. On arrival to hospital they found her to be in acute respiratory distress. She was started on continuous nebulizer treatments, given steroids and azithromycin. She was doing better and 2 days later she was discharged home. She is following up in the office after hospitalization. Mother reports symptoms have been uncontrolled since leaving the hospital. Using inhaler two times a day. She denies chest tightness or SOB. Does still have a non-productive cough at times. Allergies: Bactrim, Trimethoprim, Ceclor Current Mediation: Pro Air 90mcg/spray MDI PRN bronchospasm. Mucinex 1-2 tab PO PRN bronchial secretions. Medrol dose pack. Azithromycin x 2 more days, 500 mg PO daily. PMH/SH: Asthma, never required intubation. Hospitalized four times for it. Social History: Pt and family deny tobacco, illicit drugs or alcohol use. Family History: Mother has hypertension and her father has DM. She is the only child and is unsure of the history of her grandparents. Review of Systems (ROS): Constitutional symptoms- Patient denies fever, chills, loss of appetite, difficulty sleeping. Eyes- Patient denies blurred vision, difficulty focusing. ENT- Patient denies ear pain, sore throat, nasal congestion. Cardiovascular- Denies CP or SOB. Respiratory: Patient denies difficulty breathing, wheezing, pain on inspiration Gastrointestinal- Patient denies dysphagia, reflux, nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain. Musculoskeletal- Patient denies joint pain, swelling, muscle pain or cramps, neck pain or stiffness. Integumentary- Denies changes in skin, rash, or bruising. Neurologic- Patient denies weakness, numbness. Psychiatric- Denies, mood changes, anxiety, depression, nervousness, insomnia. Endocrine- Patient denies polydipsia, polyphagia, polyuria. Allergic/immunologic- Patient denies seasonal allergies. OBJECTIVE DATA (O): Constitutional- VS: Temp- 99.1, BP- 104/72, HR- 89 Height- 5’0″, Weight- 82 lbs.; General Appearance: 11-year-old female, presents in no acute distress, alert and oriented x 3. Eyes- sclera white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Ear, Nose, Throat- External appearance normal- on otoscopic exam tympanic membranes clear. Hearing is intact. Nose: Bilateral nasal turbinates’ slightly swollen patent. Septum is midline. Mouth: pink, moist mucous membranes. Throat: no inflammation or lesions present. Tonsils WNL. Cardiovascular- S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs. Extremities: no cyanosis, clubbing, or edema, less than 2 second refill noted. Respiratory- Clear bilaterally, no wheezing or rhonchi. Symmetrical chest rise, no use of accessory muscles. Gastrointestinal- abdomen soft and nontender to palpation, nondistended. Bowel sounds present in all 4 quadrants. Musculoskeletal- Normal ROM, joint stability normal in all extremities, no tenderness to palpation. Integument/lymphatic- Inspection: No scaling, redness or breaks on neck, or arms, or trunk. Skin warm, dry and intact with good skin turgor. Neurologic- Grossly alert and oriented x3, communication ability within normal limits. Psychiatric- Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm, and cooperative. Lymph nodes not palpable. Health Science Science Nursing NURSING NU623 Share QuestionEmailCopy link Comments (0)
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