Ecivon - Asthma Patient Case

Sandra Powel is a 13 year old white female diagnosed with asthma at 8 years of age. Sandra visits your pharmacy and her mom enrolls her in your asthma care program. You are to work with Sandra to manage her asthma and prevent complications. Recently Sandra has had some changes with her breathing as her asthma appears to be worsening. She uses her albuterol three to four times a week. Sandra has been waking up at night two to three times a month with shortness of breath. Sandra has also had wheezing during the day three times a week.

CC: "I want to be on the junior high track team this year and I'm not sure if I'm doing as good with my asthma as I can. I haven't been feeling right."

HPI: SP is a 13 year old white female with a five year history of mild intermittent asthma.

PMH: RSV as a newborn.

FH: One older sibling in good health. Parents smoke, Father has history of MI, hypertension, and hypercholesterolemia. Mother has history of depression.

SH: Started jogging recently in preparation for track season.

Meds: Albuterol PRN

ALL: NKDA

PE:

Gen: WD, 13 year old WF in NAD, 4'11", 103 lbs., BP 110/65 mm Hg, HR 78

HEENT: NC/AT, EOMI, PERRLA

CV: WNL

Lungs: Clear to auscultation, + bilateral breath sounds, best peak flow 340 L/min, FEV1 80%