Physical Exam and Laboratory Findings:
for Case #1 - Contributed by Benjamin Interiano, M.D., Department of Medicine, Baylor College of Medicine
Physical Exam:
The physical examination revealed a slightly obese Latin American female in mild respiratory distress. She is normocephalic, pupils are symmetrical and reactive, conjunctiva are hyperemic. Nasal mucosa are edematous, pink, with
increased clear secretions. No polyps. Pharynx is slightly hyperemic without exudates. Neck is unremarkable. Chest is symmetrical. Auscultation shows diffuse expiratory wheezes in both lung fields without crackles or ronchi. Heart rate is 100 and reg
ular. No murmurs. Rest of physical exam is within normal limits.
Laboratory:
CBC:Hb 13.2, Ht 43, WBCs 10500--Neut 64%, Lymphs 20%, Eos 6%
SMA 15
- BUN 18
- Creatinine 0.7
- Glucose 103
- Uric Acid 3.1
- Cholesterol 234
- Triglycerides 106
- Calcium 9.3
- Phosphorus 2.8
- Total Protein 6.7
- Albumin 4.1
- Glob 2.5
- Total Bilirrubin 0.9
- Alk Phos. 69
- ALT 21
- AST 33
- LDH 256
Ig E Level: 790
CXR: Normal
Spirometry: FVC is 85% or predicted
FEV1 is 65% of predicted.
FEV1/FVC ratio is 67%.
Improvement in FEV1 after inhaled albuterol: 22%.
Allergy testing revealed allergies to dust mites, cats, dogs, and grass.
Clinical Students:
Propose a diagnosis based on the information above and outline a management and patient counselling plan.
Compare your assessment and plan with the clinician's (case1ass.html). Did your assessment agree with the clinician's? Was the patient counselling plan adequate? If not, how could it be improved?
Pre-clinical Students:
Read the assessment and management plan. Does the management and counselling plan address all of the sociocultural issues you listed earlier? Which ones were left out? How would you add
ress these if this were your patient?
Hispanic Health Home Page
Case #1 - Contributed by Benjamin Interiano, M.D., Department of Medicine, Baylor College of Medicine