Activity 3.3.

2: Medical History Visit #3

Patients Name: Age: Date:
Melissa Martin 11 February 25
Height: Weight: Temperature:
52 inches 71 lbs. 98.9F
Blood Pressure: Pulse: Respiration Rate:
106/68 68 bpm 20 bpm

Case History

At this appointment Melissa appears a bit run down, but she is in good spirits. She
reports that one day at school this week she started to wheeze during gym class.
As she became more self-conscious about it, she started to feel tightness in her
chest and the wheezing intensified. She used the inhaler that was provided to her
and felt almost immediate improvement. She says that within a few minutes, she
was able to breathe easier and the wheezing got better. She took it easy the rest
of the day, and she has not had an incident of that nature since. She does report
that she feels like she is, however, getting a cold and reports a low grade
headache.

Physical Exam
Patients pulse is normal. Pulse ox 90%
Slight wheezing is appreciated. Lungs are clear.
Patient said she has no ear pain or a sore throat. Upon inspection, her ears
are clear; however, her nasal passageways are slightly inflamed and
irritated.
Patients glands are not swollen.
Patients speech, hearing, and vision appear normal.

Clinical Test Results

Spirometry was completed at this visit. Results indicate an average total lung
capacity. However, FEV1 was measured as 79%. After administration of albuterol,
a short-acting bronchodilator, FEV1 was measured again at 93%. This response
indicates that the impairment is reversible.

Diagnosis/Follow Up
Exercise-induced asthma- which causes shortness of breath, wheezing,
coughing, chest tightness and other symptoms during or after exercise. A
possible cause of her asthma could be from her many respiratory infections
in the past. She is advised to take it easy in gym and engage in physical
activity only if she is comfortable and careful so it doesnt trigger
symptoms. Melissa also needs to always have an inhaler close by incase of
an attack. Id like a follow up appointment with her in a month to track her
progress and see if she is more able to control her asthma.

2014 Project Lead The Way, Inc.

Human Body Systems Activity 3.3.2 Medical History Visit #3 Page 1
Medications
Melissa was provided prescriptions for both a short term rescue
medication as well as a long term control medication. Copies of the
prescriptions are included below.

Accolate- brand name (generic name- Zafirlukast), take by mouth twice a

day after meals, this is the long term control medication. Accolate is a
leukotriene inhibitor that is used to manage allergies, as well as prevent
asthma. Leukotrienes are chemicals your body releases when you breathe
in an allergen. These chemicals cause swelling in your lungs and tightening
of the muscles around your airways, which can result in asthma symptoms.
So, Zafirlukast prevents that chemical reaction to treat and ease asthma.
Possible side effects include: nausea, diarrhea, stomach pain, headache, or
cold symptoms such as stuffy nose, sneezing, and sore throat. If Melissa
experiences any of the following reactions she should call a doctor:
depressed mood, unusual thoughts or behavior, severe sinus pain or
congestion, numbness or tingly feeling in your arms or legs, worsening or
no improvement in your asthma symptoms, liver problems--nausea, upper
stomach pain, itching, tired feeling, loss of appetite, dark urine, clay-
colored stools, jaundice, or high levels of certain white blood cells--skin
rash, bruising, severe tingling, pain, muscle weakness, new or worsening
cough, fever, and trouble breathing.

Albuterol sulfate- generic name (brand name- Proventil), inhale 1-2

inhalations every 4-6 hours as needed and 2 before exercise, this is the
rescue medication. Albuterol belongs to a class of drugs known as
bronchodilators. It works in the airways by opening breathing passages and
relaxing muscles. Common side effects include: headache, dizziness, sleep
problems, cough, hoarseness, sore throat, runny or stuffy nose, nausea,
vomiting, dry mouth and throat, muscle pain, or diarrhea. Serious side
effects that need medical attention include: wheezing, chest tightness,
trouble breathing, nervousness, shaking, headache, chest pain,
palpitations, low potassium, confusion, uneven heart rate, extreme thirst,
increased urination, leg discomfort, muscle weakness or limp feeling, or
dangerously high blood pressure, severe headache, blurred vision, buzzing
in your ears, anxiety, confusion, chest pain, shortness of breath, uneven
heartbeats, and seizure.

2014 Project Lead The Way, Inc.

Human Body Systems Activity 3.3.2 Medical History Visit #3 Page 2
 PLTW Medicine
PLTW Medicine
3939 Priority Way South Drive3939 Priority Way South Drive
Indianapolis, IN 46240 Indianapolis, IN 46240

Name: Melissa Martin Name: Melissa Martin

Date of Birth: 5/6/03 Date of Birth: 5/6/03
Address: 1415 Anytown Road
Address: 1415 Anytown Road
Date: 2/25/15 Date: 2/25/15

CONTROL RESCUE
Accolate 10mg tab Albuterol sulfate 1.25mg/3ml
60 Sig 1-2 inhalations q4-6h PRN; 2
Sig 10mg PO bid pc inhalations before exercise

Generic Substitution Allowed X Generic Substitution Allowed X

Dispense as Written 10MG tab 60 / Dispense as Written 1.25mg/3mL

Sig 10mg

STP STP
Signature of Prescriber Signature of Prescriber

Refill 0 1 2 3 Refill 0 1 2 3

2014 Project Lead The Way, Inc.

Human Body Systems Activity 3.3.2 Medical History Visit #3 Page 3