NR603 Week 2 Soap

Cathy, 48 F CC: Difficulty breathing with exercise HPI: Cathy is a 48year old female who comes in to the clinic with complains of increased difficulty breathing with exercise. She reports an onset of about 2 weeks ago after recovering from a spring cold. She reports breathlessness that requires her to use 2 puffs of albuterol before running, without effect. She admits to low endurance and energy making it difficult for her to run her usual 5mile run. Cathy denies any chest tightness but has not tried to run without using inhaler. Her husband reports she is snoring at night and has woken up once or twice in the past 2 weeks because of coughing. OLDCART/ROS O: What symptoms are you experiencing? When did it start? About 2 weeks? L: Are your symptoms generalized or localized in on area of your body? Which part of your body is affected by your symptoms? D: Do your symptoms start immediately when you start exercising, or does it come and go? Does your symptoms appear sometime during a workout or after? How long do the symptoms last? C: Describe your symptoms. Do you experience breathing difficulties when you're not exercising? Do you still have cough? If yes, does your cough come and go?, do you cough up phlegm? What is the color? Any chest pain/tightness? Any tenderness, swelling, headache? Any fever, runny nose, hoarseness, enlarged tonsils? Sore throat? Swollen glands? Are your glands tender? Does SOB, wake you up from a dead sleep, during the night? A: What makes your symptoms worse? Running. R: Does anything make your symptoms better? T: Treatments: Have you used any medication or other OTC or prescription medications for your symptoms. (2 puffs albuterol inhaler before running). Have you lost weight, coughed up blood, been in contact with anyone with tuberculosis (TB) or travelled abroad recently? What are your typical workouts or recreational activities? Have you recently made changes to your exercise routine? Do the symptoms occur every time you exercise or only in certain environments? Have you been diagnosed with allergies or asthma? What other medical conditions do you have? Have you ever been diagnosed with COPD, bronchitis in the past? Any previous diagnosis of respiratory infection in the past? What medications do you take? What is the dosage of each medication? What dietary supplements or herbal medications do you take? PMHx: Chickenpox and Mumps as a child, seasonal allergies (spring is her worst season). Was seen by an allergy specialist 10 years ago, Took allergy shots for 5 years with great results Surgeries: cholecystectomy, Cheilectomy right great toe. Hospitalizations: childbirth x 3. Immunizations: UTD on all vaccinations. Allergies: Erythromycin (severe GI upset), Seasonal allergies Medications: Multivitamin, Vit. E, CoQ10, fish oil, Zyrtec, Albuterol inhaler. Social: Married, lives with husband and 3 children and 3 dogs that sleep in their bedroom. Works as a cashier at Wal-Mart. Drinks alcohol socially, smoked for 10 years in her 20's; quit at age 35. Denies illicit drug use. Sleeps 6 to 7 hours a night. Exercises 4 to 5 days per week. Family History: Mother at age 51 from brain tumor, also had breast cancer at age 32. Father died from lung CA, diagnosed when metastasized to brain. PGM: died from pancreatic CA, PGF: Alzheimer’s, died at 82. MGM: died at 83, had HTN, atherosclerosis and many heart attacks. MGF: dies at 71 from pleurisy. Children are healthy ROS: CONSTITUTIONAL: -fever. - chills. HEENT: - Dizziness, (+) headaches, - changes in vision, - ear pain, (+)nasal drainage, - sore throat. CARDIOVASCULAR: - chest pain, - palpations, - edema lower extremities. RESPIRATORY: -(+)shortness of breath on exertion, (+) wheezing, (+)cough, (-) hemoptysis. GASTROINTESTINAL: - nausea, - vomiting, - diarrhea, -decreased appetite. GENITOURINARY: - dysuria, - urgency, - urinary incontinence, -amenorrhea. NEUROLOGICAL: (-)Lethargy, - fatigue, - weakness, - difficulty with speech, - problems with gait, - burning and tingling of lower extremities. INTERGUMENTARY: (-)Rash MUSCULOSKELETAL: - muscle pain, HEMATOLOGIC:- rash, - bruising. LYMPHATIC: - swollen or tender nodes, - cold/heat intolerance. PSYCHIATRIC: (-) anxiety, (- )depression O: Physical Exam: Height 5’5”, Weight 148 pounds, BP 130/72, T 98.0, P 62, R 16 Sao2 98%. PEF< 80%, FEV1/FVC >85%. Uses < 1 albuterol inhaler/year General: 48-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 pale pink, no cyanosis or pallor. HEENT: Head normocephalic. 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 and tragus nontender Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses nontender 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 tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight wheezing noted on forced expiration. CV: Heart S1 and S2 noted, RRR