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Med Surg Case Study #7

Presenting Complaint: Sarah, a 6-year-old girl, is brought to the pediatric clinic by her parents with complaints of recurrent episodes of coughing, wheezing, and shortness of breath over the past few months. Her parents report that these symptoms often worsen at night and during physical activity.


Patient Background: Sarah is a 6-year-old girl with a history of eczema and allergies to dust mites and pet dander. She is an active child who enjoys outdoor activities. She has had frequent upper respiratory tract infections in the past.


Assessment: Upon examination, Sarah appears anxious and uses accessory muscles to breathe. She has a respiratory rate of 24 breaths per minute, heart rate of 110 beats per minute, and normal blood pressure. Lung auscultation reveals wheezing upon expiration. Her oxygen saturation is 92% on room air. She has a history of recurrent cough, and her parents report nighttime awakenings due to coughing and shortness of breath.


1. Based on Sarah's history and assessment findings, what is the possible diagnosis for her condition?


2. What diagnostics might be used to confirm the diagnosis?


3. What treatments might be needed for Sarah's condition?




See answers below





Med Surg Notebook




Answers

1. What are the possible diagnoses for Ms. Anderson's condition?

  • The possible diagnosis for Sarah's condition is asthma, characterized by recurrent episodes of coughing, wheezing, and shortness of breath, often triggered by allergens and physical activity.

2. What diagnostics might be used to confirm the diagnosis?

  • Diagnostic tests used to confirm asthma and assess its severity may include pulmonary function tests, such as spirometry, to assess lung function and bronchodilator responsiveness. Allergy testing may identify specific triggers. Additionally, chest X-rays or other imaging studies may be performed to rule out other respiratory conditions.

3. What treatments might be needed for Ms. Anderson's condition?

  • If Sarah is diagnosed with asthma, treatment may involve bronchodilators, inhaled corticosteroids, and potentially leukotriene modifiers. Her management plan may also include avoiding allergen triggers and developing an asthma action plan to manage symptoms and exacerbations.





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