Pulmonary Case Presentation for Week
2 Chamberlain University
NR 603
, PULMONARY CASE DISCUSSION 2
Patient Information:
M.G. is a 40 y/o female, Caucasian, and insurance unknown.
(S) Subjective:
CC: Pt. states, “I think I may have a cold. I've been having a hard time breathing on and off
lately."
HPI:
Short of breath at work (day shift) but notices she feels better after getting home.
No SOB noted during weekends (off from work?) SOB returns when she returns to work.
Relief noted a few months ago during SOB episode when treated with breathing treatment and
sent home with antibiotic (ABT) at urgent care.
No sputum or heartburn noted.
No new triggers for allergies noted.
Allergies: Strawberries- Rash and Erythromycin- Severe GI symptoms
Current Medications: Multivitamin and Zyrtec
PMHx: Seen by allergy specialist 10 years ago (Allergy shots for 5 years). Has seasonal allergies
and takes Zyrtec PRN. Eczema as a child
PSHx: Tonsillectomy and Cholecystectomy
Other Hospitalizations: Child Birth x 3
Immunizations: up-to-date with all immunizations
Family Hx: Parents are deceased. Mother died at 80 from CHF and Father died at 82 from Lung
cancer that metastasized to the brain. Maternal GM- died at 83 had HTN, multiple MI’s and
atherosclerosis. MGF- died at 71 from complications of COPD. PGM- unknown causes. PGF-
died at 82 from CVA. Children are overall healthy, but one daughter has a sinus infection.
Social Hx: Lives with husband and 3 children. Currently works as a bakers’ assistant at an
Artisan Bread Bakery. She begins baking breads/pastries for the day at 4 a.m. As a result, she
sleeps 6 to 7 hours per night. Currently does not smoke but 20 years ago smoked 1 pack per
week for 3 years. States she “drinks socially” and denies illicit drug use. Exercises 4 to 5 times
per week.
ROS
Constitutional: No reports of fever, chills, or weight loss. Has had contact with sick child (sinus
infection). Appears steady and coherent.
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