Week 2: Case Discussion: Pulmonary Part One No unread replies.No replies. Setti

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Week2: Case Discussion: Pulmonary Part OneNo unread replies.No replies.Setting: A free medical clinic that provides health care for theunder-insured.Your next patient, Michelle G., age 40, is a regular of theclinic and the last patient of the day. The chart states she is here for recentepisodes of shortness of 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 andask her what brings her to the clinic today. “I think I may have a cold.I’ve been having a hard time breathing on and off lately.”HPI: “I notice I’m short of breath mostly at work but by thetime I get home feel fine. No episodes of shortness of breath on the weekendsthat I can recall. But a few hours back at work and I start to feel like Icannot catch my breath again. A few months ago this happened and it was so badI left work and went to urgent care where they gave me a breathing treatment ofsome kind and sent me home on an antibiotic. I would like you to give meanother antibiotic. She denies sputum. No new allergy triggers noted. Shedenies heartburn.PMHx: Michelle G. reports her overall health as good.Childhood/previous illnesses: eczema as a childChronic illnesses: Has seasonal allergies, spring is her worstseason. Was seen by an allergy specialist ten years ago, Took allergy shots forfive years with great 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 inher 20’s. Denies illicit drug use.Sleeps 6 to 7 hours a night. Exercises four to five days perweek.Current medications: Multivitamin, ZyrtecSocial History: Married, lives with husband and 3 children.Worked in advertising up until 18 months ago when she got laid off. In order tohelp with the household finances she took a job as a Baker’s assistant at anArtisan Bread Bakery. She arrives at 4 a.m. every morning to begin bakingbreads/pastries for the day.Family History: Children are healthy- daughter currentlyhas a sinus infection. Parents are deceased. Mother at age 80 from congestiveheart failure. Father died at age 82 from lung cancer, diagnosed whenmetastasized 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 at71 from complications of COPD.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 noapparent distress. Alert, oriented, and cooperative. Able to speak in full sentencesand does not appear breathless. Skin: Skin warm, dry, and intact. Skin color ispale pink, no cyanosis or pallor.HEENT: Head normo-cephalic. Hair thick and distribution eventhroughout scalp.Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.Ears: Tympanic membranes gray and intact with light reflexnoted. Pinna and tragus non-tenderNose: Nares patent with thin white exudate noted. Mucosa appearsboggy and pale. Deviated septum noted. Sinuses non-tender to palpation.Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink,no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy ortenderness noted. Thyroid midline, small and firm without palpable masses.Lungs: Lungs clear to auscultation bilaterally. Respirationsunlabored. Slight wheezing noted inspiration and on forced expiration. Wheezingdoes not clear with forced cough.CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displacedPMI. Peripheral pulses equal bilaterally, no peripheral edemaAbdomen: Abdomen round, soft, with bowel sounds noted in allfour quadrants. No organo-megaly noted.Diagnostic Testing:Review of the patient’s EMR reveals an old CXR from last winterwhen she had Bronchitis.CXR Report: 11/7/2016This is a PA and lateral chest radiograph onMs. Michelle X, performed on 11/7/16. Clinical information: low grade fever,productive cough, malaise.Findings: Cardio-mediastinal silhouette isnormal. B/L lung fields are clear. There are no effusions. The bony thoraxappears normal. No opacities or fluid. Diaphragm normal.Impression: Normal chest radiograph withoutpathology..courselearn.net/lms/content/1490/49193/NR603/NR603_W2_CXR%20(2).jpg”>Click here to view CXR (Links to an external site.)Links to an external site.You suspect an obstructive/restrictive process and orderPulmonary Function TestingPre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreasedPost Bronchodilator Challenge- FEV1/FVC 75%Discussion Questions Part One:What is your primarydiagnosis for Michelle given the pattern of occurrence of symptoms, examresults, and recent history? Include the rationale and a reference for yourdiagnoses.What is your first-linetreatment plan for Michelle including medications, labs, education, referrals,and follow-up? Identify the drug class of each medication you prescribe andexactly what symptom it is targeted to address.Address Michelle’srequest for an antibiotic.Week2: Case Discussion: Pulmonary Part OneNo unread replies.No replies.Setting: A free medical clinic that provides health care for theunder-insured.Your next patient, Michelle G., age 40, is a regular of theclinic and the last patient of the day. The chart states she is here for recentepisodes of shortness of 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 andask her what brings her to the clinic today. “I think I may have a cold.I’ve been having a hard time breathing on and off lately.”HPI: “I notice I’m short of breath mostly at work but by thetime I get home feel fine. No episodes of shortness of breath on the weekendsthat I can recall. But a few hours back at work and I start to feel like Icannot catch my breath again. A few months ago this happened and it was so badI left work and went to urgent care where they gave me a breathing treatment ofsome kind and sent me home on an antibiotic. I would like you to give meanother antibiotic. She denies sputum. No new allergy triggers noted. Shedenies heartburn.PMHx: Michelle G. reports her overall health as good.Childhood/previous illnesses: eczema as a childChronic illnesses: Has seasonal allergies, spring is her worstseason. Was seen by an allergy specialist ten years ago, Took allergy shots forfive years with great 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 inher 20’s. Denies illicit drug use.Sleeps 6 to 7 hours a night. Exercises four to five days perweek.Current medications: Multivitamin, ZyrtecSocial History: Married, lives with husband and 3 children.Worked in advertising up until 18 months ago when she got laid off. In order tohelp with the household finances she took a job as a Baker’s assistant at anArtisan Bread Bakery. She arrives at 4 a.m. every morning to begin bakingbreads/pastries for the day.Family History: Children are healthy- daughter currentlyhas a sinus infection. Parents are deceased. Mother at age 80 from congestiveheart failure. Father died at age 82 from lung cancer, diagnosed whenmetastasized 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 at71 from complications of COPD.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 noapparent distress. Alert, oriented, and cooperative. Able to speak in full sentencesand does not appear breathless. Skin: Skin warm, dry, and intact. Skin color ispale pink, no cyanosis or pallor.HEENT: Head normo-cephalic. Hair thick and distribution eventhroughout scalp.Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.Ears: Tympanic membranes gray and intact with light reflexnoted. Pinna and tragus non-tenderNose: Nares patent with thin white exudate noted. Mucosa appearsboggy and pale. Deviated septum noted. Sinuses non-tender to palpation.Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink,no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy ortenderness noted. Thyroid midline, small and firm without palpable masses.Lungs: Lungs clear to auscultation bilaterally. Respirationsunlabored. Slight wheezing noted inspiration and on forced expiration. Wheezingdoes not clear with forced cough.CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displacedPMI. Peripheral pulses equal bilaterally, no peripheral edemaAbdomen: Abdomen round, soft, with bowel sounds noted in allfour quadrants. No organo-megaly noted.Diagnostic Testing:Review of the patient’s EMR reveals an old CXR from last winterwhen she had Bronchitis.CXR Report: 11/7/2016This is a PA and lateral chest radiograph onMs. Michelle X, performed on 11/7/16. Clinical information: low grade fever,productive cough, malaise.Findings: Cardio-mediastinal silhouette isnormal. B/L lung fields are clear. There are no effusions. The bony thoraxappears normal. No opacities or fluid. Diaphragm normal.Impression: Normal chest radiograph withoutpathology..courselearn.net/lms/content/1490/49193/NR603/NR603_W2_CXR%20(2).jpg”>Click here to view CXR (Links to an external site.)Links to an external site.You suspect an obstructive/restrictive process and orderPulmonary Function TestingPre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreasedPost Bronchodilator Challenge- FEV1/FVC 75%Discussion Questions Part One:What is your primarydiagnosis for Michelle given the pattern of occurrence of symptoms, examresults, and recent history? Include the rationale and a reference for yourdiagnoses.What is your first-linetreatment plan for Michelle including medications, labs, education, referrals,and follow-up? Identify the drug class of each medication you prescribe andexactly what symptom it is targeted to address.Address Michelle’srequest for an antibiotic.

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