A free medical clinic that provides

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 lastpatient 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 uplooking at a health poster on the wall. You introduce yourself and ask her whatbrings 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 feelfine. 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. Afew months ago this happened and it was so bad I left work and went to urgentcare 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 deniessputum. No new allergy triggers noted. She denies heartburn.PMHx: Michelle G. reports her overall health as good.Childhood/previous illnesses: eczema as a childChronic illnesses: Has seasonal allergies, spring is her worst season. Wasseen by an allergy specialist ten years ago, Took allergy shots for five years withgreat results, now only takes Zyrtec when needed.Surgeries: Tonsillectomy, CholecystectomyHospitalizations: childbirth x 3.Immunizations: up-to-date on all vaccinations.Allergies: Strawberries-Rash; erythromycin- severe GI upset.Blood transfusions: noneDrinks 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, ZyrtecSocial History: Married, lives with husband and 3 children. Worked inadvertising 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 BreadBakery. She arrives at 4 a.m. every morning to begin baking breads/pastries forthe day.
Family History: Children are healthy- daughter currently has a sinus infection.Parents are deceased. Mother at age 80 from congestive heart failure. Fatherdied 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 ofCOPD.PE: Height 5'10", Weight 140 poundsVital signs : BP 130/70, T 98.0, P 75, R 18 Sao2 98% on RAGeneral: 40-year-old Caucasian female appears stated age in no apparentdistress. Alert, oriented, and cooperative. Able to speak in full sentences anddoes 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-tenderNose: 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. Slightwheezing noted inspiration and on forced expiration. Wheezing does not clearwith forced cough.CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI.Peripheral pulses equal bilaterally, no peripheral edemaAbdomen: 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: 11/7/2016This 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 FunctionTestingPre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreasedPost Bronchodilator Challenge- FEV1/FVC 75%Discussion Questions Part One:? What is your primary diagnosis for Michelle given the pattern of occurrence ofsymptoms, exam results, and recent history? Include the rationale and areference for your diagnoses.? What is your first-line treatment plan for Michelle including medications, labs,education, referrals, and follow-up? Identify the drug class of each medicationyou prescribe and exactly what symptom it is targeted to address.? Address Michelle's request for an antibiotic.