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

If Melissa continues her medication there is a chance she can reach a normal
rate without medication. It is confirmed that Melissa has asthma. Melissa needs
to continue her medications. Melissa needs to track her asthma to see if there
is improvement.
She can use a peak flow meter at home to record results.

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 works by blocking chemicals produced by the body called
leukotrienes. Leukotrienes cause the lining of the breathing passages
of the lung to swell.
The most common side effects include:
headache
sore throat
cold symptoms
trouble sleeping
malaise
nausea
stomach pain
diarrhea
weakness
dizziness
muscle pain.

Albuterol sulfate is a quick relief medication. Its purpose is to open

up air ways by relaxing muscles.
The most common side effects include:
Nervousness
Shaking of a part of the body
Headache
Nausea
Vomiting
Cough
Irritation in the throat
Muscle, bone, or back pain
If any of these symptoms occur please see a doctor immediately.
 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
Albuterol
Accolate 10mg tab = Zafirlukast 10 sulfate 1.25mg/3ml =
miligram tablet Ventolin, Proventil
60 Sig (labeled as) 1-2 inhalations
Sig (labeled as) 10mg PO bidq4-6h(every
pc = 4-6 hours) PRN (as
Twice a day after meals takeneeded);
by 2 inhalations before
mouth exercise

Generic Substitution Allowed

X Generic Substitution Allowed
X

Dispense as Written Dispense as Written

STP STP
Signature of Prescriber Signature of Prescriber

Refill 0 1 2 3 Refill 0 1 2 3