NR603 Week 2 Part 1
Week 2: Case Discussion: Pulmonary Part One
Setting: A free medical clinic that provides health care for the under-insured.
Your next patient, Michelle G., age 40, is a regular of the clinic and the last patient of
the day. The chart states she is here for recent episodes of shortnessof breath.
You enter the room and Michelle G is dressed in work clothes, standing up looking at
a health poster on the wall. You introduce yourself and ask her what brings her to the
clinic today. "I think I may have a cold. I've been having a hardtime breathing on and
off lately."
HPI: "I notice I'm short of breath mostly at work but by the time I get home feel fine. No
episodes of shortness of breath on the weekends that I can recall. But afew hours back
at work and I start to feel like I cannot catch my breath again. A few months ago, this
happened and it was so bad I left work and went to urgent care where they gave me a
breathing treatment of some kind and sent me homeon an antibiotic. I would like you to
give me another antibiotic. She denies sputum. No new allergy triggers noted. She
denies heartburn.
PMHx: Michelle G. reports her overall health as good.
Childhood/previous illnesses: eczema as a child
Chronic illnesses: Has seasonal allergies, spring is her worst season. Was seen by
an allergy specialist ten years ago, took allergy shots for five years withgreat results,
now only takes Zyrtec when needed.
Surgeries: Cholecystectomy Hospitalizations:
childbirth x 3. Immunizations: up to date on all
vaccinations.
Allergies: Strawberries-Rash; erythromycin- severe GI upset.
Blood transfusions: none
Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20's. Deniesillicit
drug use.
Sleeps 6 to 7 hours a night. Exercises four to five days per week.
Current medications: Multivitamin, Zyrtec
Social History: Married, lives with husband and 3 children. Worked in advertising up
until 18 months ago when she got laid off. In order to help with thehousehold finances,
she took a job as a Baker's assistant at an Artisan Bread Bakery. She arrives at 4 a.m.
every morning to begin baking breads/pastries for the day.
Family History: Children are healthy- daughter currently has a sinus infection. Parents
are deceased. Mother at age 80 from congestive heart failure. Father died at age 82
from lung cancer, diagnosed when metastasized to brain. PGM: died from unknown
causes, PGF: Stroke at age 82. MGM: died at 83, had HTN,atherosclerosis and many
heart attacks. PGF: died at 71 from complications of COPD.
, PE: Height 5'10", Weight 140 pounds
Vital signs : BP 130/70, T 98.0, P 75, R 18 Sao2 98% on RA
General: 40-year-old Caucasian female appears stated age in no apparent distress.
Alert, oriented, and cooperative. Able to speak in full sentences and does not appear
breathless. Skin: Skin warm, dry, and intact. Skin color is palepink, no cyanosis or
pallor.
HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.Eyes:
Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna andtragus non-
tender
Nose: Nares patent with thin white exudate noted. Mucosa appears boggy andpale.
Deviated septum noted. Sinuses non-tender to palpation.
Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in
good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline.
Neck supple. No cervical lymphadenopathy or tendernessnoted. Thyroid midline,
small and firm without palpable masses.
Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight
wheezing noted inspiration and on forced expiration. Wheezing does not clear with
forced cough.
CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI.
Peripheral pulses equal bilaterally, no peripheral edema
Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants.No
organo-megaly noted.
Diagnostic Testing:
Review of the patient's EMR reveals an old CXR from last winter when she hadBronchitis.
CXR Report: 11/7/2016
This is a PA and lateral chest radiograph on Ms. Michelle X, performed on11/7/16.
Clinical information: low grade fever, productive cough, malaise.
Findings: Cardio-mediastinal silhouette is normal. B/L lung fields are clear. Thereare
no effusions. The bony thorax appears normal. No opacities or fluid.
Diaphragm normal.
Impression: Normal chest radiograph without pathology.
Click here to view CXR (Links to an external site.) (Links to an external site.)
You suspect an obstructive/restrictive process and order Pulmonary Function
Testing
Pre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreasedPost
Bronchodilator Challenge- FEV1/FVC 75%
Discussion Questions Part One:
