26 Jun Marissa is a 7 year old female coming to the clinic with increased wheezing, coughing
Question
Marissa is a 7 year old female coming to the clinic with increased wheezing, coughing, and difficulty breathing. She was diagnosed with asthma 2 years ago. She uses an albuterol inhaler to manage her symptoms and has been using it regularly 3 – 5 times a day for the past 3 months.
Medications include Albuterol HFA 2 puffs Q4H prn. Children’s multivitamin QD. Children’s chewable Vitamin C tablet QD.
Allergies: NKDA
ROS: A 14 point review of systems was negative except what is noted above.
Physical examination:
GEN: well-developed child in mild distress at visit.
VS: BP 121/78, HR 94, RR 16, T 98.5
CHEST: wheezing on inspiration and expiration
HEENT: normal
COR: normal
ABD: normal
NEURO: normal
EXT: normal
Describe your differential diagnosis list and identify your most likely primary diagnosis. Thereafter describe your next steps diagnostically and in the way of medication changes in detail with inclusion of rationale and mechanism of action.
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