Your patient is a 23-year-old female. She presents with coughing and wheezing which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her last prenatal visit was one month ago in another state. She has an appointment with the prenatal care provider next week, however her respiratory symptoms brought her to your office today.
History – Chickenpox as a child. Asthma as a child, diagnosed at age 8 for which she used a SABA when needed. She has not had the need to use an inhaler since she was 19. She takes only her prenatal vitamin. No other acute or chronic problems. She advises you that she is up to date on all immunizations except she has not had a flu shot (it is October).
Social – Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance.
HPA – Non-productive cough x 3 weeks. Wheezing audible from across the room. She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints.
PE/ROS – Pt appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular. The remainder of the exam is WNL.
02 98% and FEV 70%
Directions:
Construct a narrative document of 4-5 pages (not including cover page or reference page)
Diagnose the patient based on the above findings and provide your rationale for how you arrived at the diagnosis.
Develop a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
Describe community resources (using your own community) currently available in your state/city to support this patient.
Provide a communication plan that you will use to ensure the patient is an active participant in the treatment plan. Refer to therapeutic communication concepts.
Utilize national standards, your pharm and/or patho book, and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts.
Use references to support your concepts. Utilize correct APA formatting (7th edition) and mechanics of professional communication.
