Activity 3.3.

1: Medical History Visit #1

Patients Name:
Melissa Martin
Height:
52 inches
Blood Pressure:
110/72

Age:
11
Weight:
70 lbs.
Pulse:
75 bpm

Date:
February 5
Temperature:
98.3F
Respiration Rate:
22 bpm

Case History
Melissa is an 11 year-old girl who has been having coughing fits for the
past 6 days. Her mom is concerned as her school reports that she has been
reluctant to participate in gym class. Melissa states that she is
embarrassed that she cant keep up with her friends. She has also been
having trouble lasting her entire ballet class without feeling tired or starting
to cough. Melissas records report five upper respiratory infections and
associated coughing in the past 18 months. Mild wheezing is reported at
each of these appointments. Melissa describes the cough as dry and says
during these times of infection, she wakes up coughing more than once a
night.
Physical Exam
Patients pulse is normal. Pulse ox = 91%
No wheezing is appreciated on this appointment.
Patient said she has no ear pain or a sore throat. Upon inspection,
her ears, nose, and throat all look normal.
Patients glands are not swollen.
Patients speech, hearing, and vision appear normal..
Explanation of Symptoms
Due to the symptoms the explanation I can give is that she has a condition
called asthma. Melissa has almost all of the symptoms that asthma causes.
The big sign was it flares up more during physical activity.
Recommendations
Knowing your triggers for asthma is very important. Depending on the type
of asthma, different treatments are necessary. For Melissas case she has
exercise induced asthma. Her treatment would be to obtain an inhaler. An
inhaler is used before you do extensive work to reduce the amount of
coughing and wheezing.

2014 Project Lead The Way, Inc.

Human Body Systems Activity 3.3.1 Medical History Visit #1 Page 1

 2014 Project Lead The Way, Inc.

Human Body Systems Activity 3.3.1 Medical History Visit #1 Page 2