• Name/Initials: MG
  • Age: 40 years old
  • Gender: Female
Subjective:
  • Chief Complaint (CC): “I think I may have a cold. I’ve been having a hard time breathing on and off lately.”
  • History of Present Illness (HPI): MG reports experiencing shortness of breath (SOB) mostly at work. She feels fine by the time she gets home and does not experience these symptoms on weekends. She recalls a similar episode a few months ago that was severe enough to visit urgent care, where she was given a breathing treatment and an antibiotic. She is now seeking another antibiotic. MG denies having sputum production, new allergy triggers, or heartburn.
  • Current Medications: Zyrtec as needed for seasonal allergies.
  • Allergies:
    • Strawberries – Rash
    • Erythromycin – Severe GI upset
Past Medical History (PMHx):
  • Eczema as a child
  • Seasonal allergies
  • Tonsillectomy
  • Cholecystectomy
  • Childbirth x3
Social History (Soc Hx):
  • MG is married and lives with her husband and three children.
  • She previously worked in advertising but was laid off 18 months ago.
Assessment Considerations:
  • The patient’s symptoms of shortness of breath (SOB) that occur primarily at work and not at home or on weekends may suggest an environmental or occupational trigger. The previous resolution with a breathing treatment suggests the possibility of asthma or reactive airway disease. Given the lack of sputum, heartburn, and new allergy triggers, an infectious cause seems less likely, and the request for an antibiotic may need to be reconsidered. Environmental factors at her workplace should be further explored, and pulmonary function testing may be indicated to assess for asthma or other respiratory conditions.