Activity 3.3.

1: Medical History Visit #1

Patients Name: Age: Date:
Melissa Martin 11 February 5
Height: Weight: Temperature:
52 inches 70 lbs. 98.3F
Blood Pressure: Pulse: Respiration Rate:
110/72 75 bpm 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
Coughing fits viral infection, asthma, heartburn, bronchitis
Tired easily/quickly shortness of breath may be keeping her from getting
enough oxygen to produce enough ATP and therefore energy
Mild wheezing narrowing of airways/difficulty breathing
Dry coughing symptom of upper respiratory infection
5 upper respiratory infections infections may not have been completely
cured and untreated viruses may have remained in her system
Unable to keep up with friends shortness of oxygen and therefore energy

Recommendations
Melissas symptoms are common for asthma.
o Asthma is common in children.

2014 Project Lead The Way, Inc.

Human Body Systems Activity 3.3.1 Medical History Visit #1 Page 1
 o Shortness of breath is caused by blocked or restricted airways
o If no air is coming in, the body will not get the proper amount of energy it
needs and will therefore tire quickly.
o Melissa is not constantly wheezing and coughing, so this must be a
problem that only occurs when provoked and does not stay 24/7.
I recommend Melissa take the Peak Flow test to see where her level of asthma
is. We will further prescribe any medications or medical assistance as needed.

2014 Project Lead The Way, Inc.

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