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Joanne Bennett, 29 yr old Caucasian woman
CC: “I have a cough that won’t go away.”
S) HPI: c/o cough for one month. It began suddenly. Noticed that it started around the beginning of spring as weather became warmer. Becomes worse when goes outside, especially at night. Symptoms worse at night and often wakes with coughing. On two occasions coughing fits have caused her to throw up. Denies sputum with the cough. Concerned because during her coughing attacks she sometimes feels that she cannot catch her breath, which is “extremely frightening.” Sometimes sounds wheezy. Taking Robitussin every 4-6 hours, but this is not alleviating her cough. Sleeps w/ 1pillow. Sleeps with windows closed.
PMH: Last Physical Exam was more than 2 years ago. Was told to lose wt. No h/o of asthma or bronchitis. Surgery: none. No hospitalizations.
Meds: birth control pills (Lo-Ovral for the past 2 years). OTC Claritin 10mg for seasonal allergies taken occasionally.
Allergies: NKDA; no food allergies. Seasonal allergies to pollen. Sleep: 8 hours/night when not coughing. TB skin test neg 6 months ago. Flu shot last winter.
SH: works full time as a receptionist in a corporate office building x 2yrs. Sedentary lifestyle. Her only exercise is walking 3 blocks from BART station to work each day. Non-smoker. Denies drug use. ETOH occasionally. 3 cups of coffee daily. Lives alone in apt; in no current relationship. Has no pets.
FH: Father: 56, smoker, asthma, COPD, HTN PGF: asthma; died age 56 in MVA
Mother: 55, smoker, DM type 2, HTN PGM: 78, alive with Alzheimer
MGF: died age 68 from CVA Brother: 25, asthma, obesity
MGM: died age 70 from CVA, DM type 2
ROS: General: Denies recent weight changes, fevers, or chills.
Derm: Denies rash
HEENT: Voice hoarse; no throat pain. No nasal d/c. Denies sinus pain or pressure.
Resp: See HPI
CV: Denies chest pain or SOB with exertion.
Endocrine: Denies excessive hunger, thirst or excessive urination.
MS: Chest muscles tight from coughing. Has mild knee pain sometimes esp with going up stairs.
Psych: Denies depression, thoughts of harm to self or others.
O) Vitals: Temp: 98.5, BP: 124/85, RR: 16, HR: 70, O2 sat: 98%, Height: 5’2″, wt: 168 lbs BMI: 31
General: obese. Wheezing with inspiration.
Skin: pale. No excessive dryness.
HEENT: Canals clear. TMs visible, translucent, gray, cone of light and landmarks visible. Nasal mucosa pink, clear d/c, septum midline. Oral mucosa pink and moist, no pharyngeal erythema, no exudates, tonsils 2+. No frontal/maxillary sinus tenderness. Neck supple, trachea mid-line. No LAD. Thyroid without enlargement or nodules.
Heart: normal S1, S2, No MRG
Lungs: Diffuse expiratory wheezes throughout. Resonant to percussion, thoracic expansion equal. No increased AP/lateral diameter. No egophany. Tactile fremitus equal.
Extremities: No edema, pulses equal 2+ bilaterally in all 4 extremities.
A) Asthma, triggered by seasonal allergies.
P) #1. Rx: Albuterol HFA MDI 2 puff q 4-6 hours prn wheezing/cough. Flovent MDI 40 mcg 2 puffs BID. Claritin 10mg q am.
Dx: none
Pt. Ed: Teach use of peak flow meter; begin learning to self-monitor asthma. Rinse mouth after use of steroid inhaler,
F/U: RTC in 2 weeks; bring log of symptoms and use of rescue inhaler.
SCIENCE
HEALTH SCIENCE
NURSING
