Running head: WEEK 2 Week 2 Crystal Quince Chamberlain College of Nursing NR 603: Advanced Clinical Diagnosis and Practice Across the Lifespan October 2017 2 WEEK 2 Week 2: PBL Case Discussion... : Pulmonary Part two Name: Margaret R. Sex: Female Age: 40 Race: Black Insurance: NA CC: The chart states she is here for recent episodes of shortness of breath. She states, “I think I have a cold. I’ve been having a hard time breathing on and off lately.” HPI: “I am short of breath sometimes and I’m not overly exerting myself when it happens. Sometimes it happens when I’m walking, talking or sitting. Reports that she has been noticing over the last three months that she has been getting short of breath during the week. 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 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 denies sputum. No new allergy triggers noted. She denies heartburn. PMHx: Margaret R. reports her overall health as good. Childhood/previous illnesses: chickenpox and 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 with great results, now only takes Zyrtec when needed. Surgeries: Tonsillectomy, Cholecystectomy Hospitalizations: childbirth x 3. Immunizations: up-to-date on all vaccinations. [Show More]
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