Setting: A free medical clinic that provides health care for the under-insured.
Your next patient, Michelle G., age 40, is a regular of the clinic and the last patient of the day. The chart states she is here for recent episodes 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 and ask 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 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: Michelle G. reports her overall health as good.

Childhood/previous illnesses: 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: Cholecystectomy

Hospitalizations: childbirth x 3.

Immunizations: up-to-date on all vaccinations.

Allergies: Strawberries-Rash; erythromycin- severe GI upset.

Blood transfusions: none

Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20’s. Denies illicit drug use.

Sleeps 6 to 7 hours a night. Exercises four to five days per week.

Current medications: Multivitamin, Zyrtec

Social History: 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.

Family History:Children are healthy- daughter currently has a sinus infection. 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 and many heart attacks. PGF: died at 71 from complications of COPD.

PE: Height 5’10”, Weight 140 pounds

Vital signs : BP 130/70, T 98.0, P 75, R 18 Sao2 98% on RA

General: 40-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 normo-cephalic. 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 non-tender

Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses non-tender 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 inspiration and on forced expiration. Wheezing does not clear with forced cough.

CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.

Diagnostic Testing:

Review of the patient’s EMR reveals an old CXR from last winter when she had Bronchitis.

CXR Report: 11/7/2016

This is a PA and lateral chest radiograph on Ms. Michelle X, performed on 11/7/16. Clinical information: low grade fever, productive cough, malaise.

Findings: Cardio-mediastinal silhouette is normal. B/L lung fields are clear. There are no effusions. The bony thorax appears normal. No opacities or fluid. Diaphragm normal.

Impression: Normal chest radiograph without pathology.

Click here to view CXR(Links to an external site.) (Links to an external site.)

You suspect an obstructive/restrictive process and order Pulmonary Function Testing

Pre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreased

Post Bronchodilator Challenge- FEV1/FVC 75%

Discussion Questions Part One:
What is your primary diagnosis for Michelle given the pattern of occurrence of symptoms, exam results, and recent history? Include the rationale and a reference for your diagnoses.
What is your first-line treatment plan for Michelle including medications, labs, education, referrals, and follow-up? Identify the drug class of each medication you prescribe and exactly what symptom it is targeted to address.
Address Michelle’s request for an antibiotic.

please answer each question with different paragraphs.