Clinical case A 22-year old woman with a past medical history of asthma diagnosed at the age of 16 is admitted for shortness of breath. She is nauseated and has vomited once today. Yesterday, she was exposed to dust, one of her known triggers, while reorganizing her room. Since then she has had shortness of breath with exertion, excess mucous production, and cough like her previous “asthma attacks”. ​She has been taking her daily inhalers for asthma but without relief. Review of systems: - She denies pleuritic pain, sick contacts, and fevers. She is exposed to second-hand smoke from her roommates. She has not had chest pain, leg swelling, or recent prolonged travel. Past medical: - Medical history: Asthma, diagnosed age 16. In the past year, she has been hospitalized twice. - Surgical history: She has had no prior surgeries. - Family history: Her mother has asthma, well-controlled now that she has stopped smoking. - Social history: She denies smoking, drinking, and using illicit drugs. Meds/allergy: - Fluticasone/Formoterol inhaler twice a day for her asthma - She has no known drug allergies Physical examination: - Vital signs: Temp: 37.2c, BP: 140/90 mmHg, HR: 100, RR: 26, Oxygen saturation: 92% on room air. - General appearance: anxious, tired-appearing woman, in obvious respiratory distress: - Cardiovascular: Tachycardic but regular rhythm; no murmurs,; pulses bounding in all extremities - Pulmonary: breathing with mouth open; minimal air movement especially at bases with expiratory wheeze even more clearly heard on auscultation; no rales or rhonchi but begins coughing with deep inspiration. She was unable to full sentences without feeling shortness of breath and using accessory muscles to aid respiration. - Abdomen: Nontender; non-distended; positive bowel sounds; no organomegaly. - Extremities: No clubbing or cyanosis. > How will you clinically assess her respiratory status and evaluate if the patient is not sick, sick, or really sick (the severity) based on the presenting information? > What are your likely explanation for signs and symptoms in this case? > What is your approach to this patient? - What information do you need more in history taking & physical exam? - What investigation tests will you order to gather information and why? - What is the most likely diagnosis for this patient?​Reflect on the case, how will you assess the respiratory status of this patient based on presenting information and based on vital signs, how will you assess the severity of the patient if she is not sick, sick or really sick​?