13 Jan Setting: A free medical clinic tha
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 lastpatient of the day. The chart states she is here for recent episodes of shortnessof breath.You enter the room and Michelle G is dressed in work clothes, standing uplooking at a health poster on the wall. You introduce yourself and ask her whatbrings her to the clinic today. "I think I may have a cold. I've been having a hardtime breathing on and off lately."HPI: "I notice I'm short of breath mostly at work but by the time I get home feelfine. No episodes of shortness of breath on the weekends that I can recall. But afew hours back at work and I start to feel like I cannot catch my breath again. Afew months ago this happened and it was so bad I left work and went to urgentcare where they gave me a breathing treatment of some kind and sent me homeon an antibiotic. I would like you to give me another antibiotic. She deniessputum. No new allergy triggers noted. She denies heartburn.PMHx: Michelle G. reports her overall health as good.Childhood/previous illnesses: eczema as a childChronic illnesses: Has seasonal allergies, spring is her worst season. Wasseen by an allergy specialist ten years ago, Took allergy shots for five years withgreat results, now only takes Zyrtec when needed.Surgeries: Tonsillectomy, CholecystectomyHospitalizations: childbirth x 3.Immunizations: up-to-date on all vaccinations.Allergies: Strawberries-Rash; erythromycin- severe GI upset.Blood transfusions: noneDrinks alcohol socially, smoked 1 pack per week for 3 years in her 20's. Deniesillicit drug use.Sleeps 6 to 7 hours a night. Exercises four to five days per week.Current medications: Multivitamin, ZyrtecSocial History: Married, lives with husband and 3 children. Worked inadvertising up until 18 months ago when she got laid off. In order to help with thehousehold finances she took a job as a Baker's assistant at an Artisan BreadBakery. She arrives at 4 a.m. every morning to begin baking breads/pastries forthe day.
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