NURS 506 Case Study Analysis: Asthma - Liberty University

Running head: CASE STUDY ANALYSIS 1
ASTHMA




Case Study Analysis: Asthma

Name

Liberty University

, CASE STUDY ANALYSIS 2
ASTHMA
Case Study Analysis: Asthma

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