List specific goals for treatment for S.C.

Domain: History

1a) What triggers S.C.’s wheezing? 1b) It’s important to answer this question, as it will help prevent wheezing in the future and improve her asthma management. This might help identify environmental, occupational and other triggers for her asthma.

S.C. has recently been diagnosed with a viral infection of the respiratory tract? This is an important question because viral infections can trigger asthma attacks. 1c) This question might reveal whether S.C.’s current symptoms are related to a recent respiratory infection.

The Physical ASSESSment Domain

Asthma is assessed by the provider. According to information provided in the case, mild end-expiratory coughing bilaterally at the base would constitute abnormal findings. In a wellness check, abnormal findings may include abnormal breathing or decreased lung function. For the respiratory system, normal findings include no wheezing or clear breath sounds. Two diagnostic tools are needed for this patient: a peak flow meter and spirometer.

ASSESSMENT: (MEDICAL DIAGNOSIS).

Asthma (chronic inflammatory disease) of the airways is characterized by episodes of coughing, wheezing or chest tightness. The airway inflammation leads to airway hyperresponsiveness, which causes bronchoconstriction and reduced airflow. 3b). Not applicable.

DOMAIN: LABORATORY & DIAGNOSTIC TESTS

To assess the severity of asthma and lung function, a pulmonary function test (PFT) should be performed. This includes spirometry as well as peak flow measurements. In this situation, abnormal PFT results include an FEV1/FVC of 80% as well as an FEV1 that is 90% less than predicted. The abnormal PFT result suggests mild-moderate asthma and reversible obstruction of airflow. According to the diagnosis, other possible causes of respiratory symptoms may be ruled out with diagnostic tests such as chest x-rays and allergy testing. In this age group the U.S. Preventive Taskforce advises that a wellness appointment should include a screening for smoking and advice on quitting.

Plan of Care for Domain

1. S.C. is treated with specific goals, including controlling asthma symptoms and improving lungs function.
2. As a first-line treatment, inhaled corticosteroids are the preferred medication for asthma that is mild or moderate.
3. Prescription: Beclomethasone Dipropionate Inhalation 80 mcg, 2 puffs daily.
4. The improvement of symptoms, the increase in lung function and the decrease in rescue medications are all indicators that can be used to measure success.
5. Education of patients should cover proper use of inhalers, adhering to prescribed medication, avoiding triggers and recognising and reacting to acute exacerbations.
6. Hoarseness and oral thrush are two adverse reactions that could warrant a switch in treatment. Other systemic side effects include decreased bone density in children or growth inhibition.
7. The second line of therapy for asthma includes leukotriene moderators, beta-agonists with a longer half-life, or ICS combined with a long acting beta-agonist.
8. Patients with asthma should avoid over-the-counter medicines such as beta-blockers and nonsteroidal antiinflammatory drugs (NSAIDs).