Zack is afebrile with a respiratory rate of 36 and a tight cough every 1 or 2 minutes. He weighs 45 pounds.
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SOUTH UNIVERSITY
Zack is afebrile with a respiratory rate of 36 and a tight cough every 1 or 2 minutes. He weighs 45 pounds.
Paper Instructions
Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case Family Medicine 07 53-year-old male with leg swelling.
You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.
DOMAIN HISTORY
Identify two (2) additional questions that were not asked in the case study and should have been?
Explain your rationale for asking these two additional questions.
- Describe what the two (2) additional questions might reveal about the patient’s health.
DOMAIN PHYSICAL EXAM
For each system examined in this case;
Explain the reason the provider examined each system.
- Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
Describe the normal findings for each system.
Identify the various diagnostic instruments you would need to use to examine this patient.
DOMAIN ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the
- Diagnosis and,
- Each Differential Diagnosis
- If it is a Wellness, type ‘Not Applicable’
DOMAIN LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
- What labs should be ordered in the case?
- Discuss what lab results would be abnormal.
- Discuss what the abnormal lab values indicate.
- Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
- If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.
Submission Details
- Post your initial response to the Discussion Area by Day 3. Respond to at least two posts by the end of the week, Day 7. The week starts on Tuesday and ends on the following Monday.
- Your initial post is due on Day 3.
- Your two peer responses are due no later than Day 7. The expectation is that you reply to your peers on more than 2 days before the end of the week to receive full credit.
- Please make sure you are using scholarly references and they should not be older than 5 years. Your posts/references must be in APA format.
- Please follow the discussion rubric to make sure you have addressed the discussion criteria.
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Sample Answer
Week 4 Case Study
Which medications do you feel are safe and appropriate to utilize initially
The patient would initially benefit from a Rapid-acting beta2-agonist like Albuterol. Albuterol treats bronchospasm in acute asthmatic episodes, similar to what the patient is experiencing. It also prevents bronchospasm linked with exercise-induced or nocturnal asthma (Martin et al., 2022).
In addition, if the patient’s condition worsens to a severe exacerbation, he would benefit from a systemic corticosteroid like Prednisone. Systemic corticosteroids are used for short periods (3-10 days) and would help the patient achieve prompt control of the inadequately controlled acute asthmatic episodes (Martin et al., 2022).
Which medications do you feel will be safe and appropriate to prescribe and/or recommend for chronic, ongoing management?
Zack has been on Albuterol, which is in Step 1 of the stepwise approach to asthma treatment. The appropriate drug for chronic asthma management would be a medication in Step 2. I would recommend low-dose Beclomethasone, an inhaled corticosteroid which is the first choice in Step 2 (Gaillard et al., 2021).
Beclomethasone would benefit the patient by alleviating asthma symptoms, improving airway function, and reducing peak flow variability (Ban et al., 2018). Alternatively, the patient can be prescribed a Leukotriene blocker such as Montelukast (Gaillard et al., 2021). This is an anti-inflammatory agent and potent bronchoconstrictor.
References
- Gaillard, E. A., Kuehni, C. E., Turner, S., Goutaki, M., Holden, K. A., de Jong, C. C., … & Moeller, A. (2021). European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5–16 years. European respiratory journal, 58(5). https //doi.org/10.1183/13993003.04173-2020
- Martin, J., Townshend, J., & Brodlie, M. (2022). Diagnosis and management of asthma in children. BMJ paediatrics open, 6(1), e001277. https //doi.org/10.1136/bmjpo-2021-001277
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