Chamberlain University NR603: Advanced Clinical Diagnosis and Practice Across Lifespan March 2018
Patient Information: M.G., 40-year-old female, race unknown, insurance unknown.
Subjective: CC: “I think I may have a cold. I’ve been having a hard time breathing on and off lately.”
HPI: M.G. reports that she experiences shortness of breath (SOB) mostly while at work, which subsides when she returns home. She does not recall having episodes of SOB on weekends. However, after a few hours back at work, she starts feeling like she cannot catch her breath again. A few months ago, she experienced such severe SOB that she had to leave work and visit urgent care, where she received a breathing treatment and was prescribed an antibiotic. She is now requesting another antibiotic. M.G. denies producing sputum, noticing any new allergy triggers, or experiencing heartburn.
Current Medications:
- Multivitamin
- Zyrtec
Allergies:
- Strawberries: Rash
- Erythromycin: Severe gastrointestinal upset
Past Medical History (PMHx): M.G. reports her overall health as good. She has seasonal allergies, with spring being the worst season. She was seen by an allergy specialist ten years ago and received allergy shots for five years with great results. Currently, she only takes Zyrtec as needed.
Past Surgical History (PSHx):
- Tonsillectomy
- Cholecystectomy
Childhood Illnesses:
- Eczema as a child
Immunization History:
- Up-to-date on all vaccinations
Other Screenings:
- Not reported
Social History (Soc Hx): M.G. is married and lives with her husband and three children. She previously worked in advertising until 18 months ago when she was laid off. To help with household finances, she took a job as a baker’s assistant at an Artisan Bread Bakery. She begins her workday at 4 a.m., baking bread and pastries. M.G. drinks alcohol socially, smoked one pack of cigarettes per week for three years in her 20s, and denies any illicit drug use. She sleeps 6 to 7 hours a night and exercises four to five days per week.
Family History (Fam Hx):
- Children: Healthy; one daughter currently has a sinus infection.
- Mother: Deceased at age 80 from congestive heart failure.
- Father: Deceased at age 82 from lung cancer, which metastasized to the brain.
- Paternal Grandmother: Died from unknown causes.
- Paternal Grandfather: Died at age 82 from a stroke.
- Maternal Grandmother: Died at age 83 from hypertension, atherosclerosis, and multiple heart attacks.
- Maternal Grandfather: Died at age 71 from complications of COPD.
Review of Systems (ROS):
- CONSTITUTIONAL: No reports of fever, chills, or weight loss. Reports contact with a sick daughter who has a sinus infection.
- HEENT: None reported.
- SKIN: None reported.
- CARDIOVASCULAR: None reported.
- RESPIRATORY: Shortness of breath at work. Denies sputum production.
- GASTROINTESTINAL: Denies heartburn.
- GENITOURINARY: None reported.
- NEUROLOGICAL: None reported.
- MUSCULOSKELETAL: None reported.
- HEMATOLOGIC/LYMPHATICS: None reported.
- PSYCHIATRIC: None reported.
- ENDOCRINOLOGIC: None reported.
- ALLERGIES: Allergic to strawberries and erythromycin. Reports seasonal allergies, with spring being the worst season.
This detailed case presentation provides a comprehensive overview of M.G.’s health status, focusing on her current symptoms, medical history, and relevant social and family background, which can guide further diagnostic evaluation and management.