Chamberlain College of NursingNR 603NR603 Week 2 Case Summary

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Running head: WEEK 2: SUMMARY 1 Week 2: Case Presentation Summary Chamberlain University NR603: Advanced Clinical Diagnosis and Practice Across Lifespan March 2021 SOAP Week 2 Patient Informatio... n: M.G., 40-year-old female, race unknown, insurance unknown. (S) Subjective: CC: "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 the time 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 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 home on an antibiotic. I would like you to give me another antibiotic. She deniessputum. No new allergy triggers noted. She denies heartburn. Current Medications: Multivitamin Zyrtec Allergies: Strawberries-Rash; erythromycin-severeGI upset. WEEK 2: SUMMARY 2 PMHx: Michelle G. reports her overall health as good. Hasseasonal allergies, spring is her worstseason. Wasseen by an allergy specialist ten years ago, took allergy shotsfor five years with great results, now only takes Zyrtec when needed. PSHx: Tonsillectomy, Cholecystectomy Childhood Illnesses: eczema as a child Immunization Hx: up-to-date on all vaccinations. Other Screenings: Not reported. Soc Hx: 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 the household 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. Drinks alcohol socially, smoked 1 pack per week for 3 yearsin her 20's. Deniesillicit drug use. Sleeps 6 to 7 hours a night. Exercisesfour to five days per week. Fam Hx: Children are healthy- daughter currently has a sinusinfection. 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 andmany heart attacks. PGF: died at 71 from complications of COPD. ROS: CONSTITUTIONAL: No reports of fever, chills, weight loss. Report sick contact-daughter hassinus infection. HEENT:None reported. SKIN: None reported. CARDIOVASCULAR: None reported. RESPIRATORY: Shortness of breath at work. Deniessputum. GASTROINTESTINAL: Denies heartburn. GENITOURINARY: None reported. NEUROLOGICAL: None reported. MUSCULOSKELETAL: None reported. HEMATOLOGIC/LYMPHATICS: None reported. PSYCHIATRIC: None reported. ENDOCRINOLOGIC: None reported. ALLERGIES: Strawberries and erythromycin. Reports seasonal allergies-spring is worst. O: Vital signs: B/P 130/70, T 98.0, HR 75, RR 18 Sao2 98% RA. Height 5’10”, weight 140 pounds BMI: 20.1 PHYSICAL EXAM GENERAL: 40-year-old Caucasian female appearsstated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless [Show More]

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