y

Patient Information:
  • Name: M.G.
  • Age: 40 years old
  • Gender: Female
  • Ethnicity: Caucasian
  • Insurance Status: Unknown

Subjective:

  • Chief Complaint (CC):
    • Patient states, “I think I may have a cold. I’ve been having a hard time breathing on and off lately.”
  • History of Present Illness (HPI):
    • M.G. reports experiencing shortness of breath (SOB) primarily during her work shifts (day shift) as a baker’s assistant. She notices an improvement in her symptoms when she returns home and has no SOB during weekends when she is off work.
    • A few months ago, she had an episode of SOB that was relieved after receiving a breathing treatment at an urgent care center. She was also prescribed antibiotics at that time.
    • M.G. denies having any sputum production or heartburn.
    • She reports no new triggers for her allergies.
  • Allergies:
    • Strawberries: Causes rash.
    • Erythromycin: Causes severe gastrointestinal symptoms.
  • Current Medications:
    • Multivitamin
    • Zyrtec (as needed)
  • Past Medical History (PMHx):
    • M.G. was seen by an allergy specialist 10 years ago and received allergy shots for 5 years.
    • She has a history of seasonal allergies and currently takes Zyrtec as needed.
    • She had eczema as a child.
  • Past Surgical History (PSHx):
    • Tonsillectomy
    • Cholecystectomy
  • Other Hospitalizations:
    • Childbirth (3 times)
  • Immunizations:
    • Up-to-date with all immunizations
  • Family History (FamHx):
    • Mother: Deceased at age 80 from congestive heart failure (CHF).
    • Father: Deceased at age 82 from lung cancer that metastasized to the brain.
    • Maternal Grandmother: Deceased at age 83 with a history of hypertension, multiple myocardial infarctions (MIs), and atherosclerosis.
    • Maternal Grandfather: Deceased at age 71 from complications of chronic obstructive pulmonary disease (COPD).
    • Paternal Grandmother: Cause of death unknown.
    • Paternal Grandfather: Deceased at age 82 from cerebrovascular accident (CVA).
    • Children: Overall healthy, but one daughter has a sinus infection.
  • Social History (SocHx):
    • M.G. lives with her husband and three children.
    • She works as a baker’s assistant at an Artisan Bread Bakery, starting her workday at 4 a.m.
    • She sleeps 6 to 7 hours per night.
    • M.G. does not currently smoke but smoked one pack per week for three years 20 years ago.
    • She reports “drinking socially” and denies illicit drug use.
    • She exercises 4 to 5 times per week.
  • Review of Systems (ROS):
    • Constitutional: No reports of fever, chills, or weight loss. She has had contact with a sick child who has a sinus infection. Appears steady and coherent.
    • HEENT: No complaints.
    • Skin: No complaints.
    • Cardiovascular: No complaints.
    • Respiratory: Reports SOB at work, no other respiratory complaints at present. Denies sputum production.

Assessment:

Differential Diagnoses:
  1. Occupational Asthma:
    • Rationale: M.G.’s symptoms of SOB are associated with her work environment, where she is exposed to potential allergens such as flour dust. The relief of symptoms when away from work supports this diagnosis.
  2. Allergic Rhinitis with Asthma Exacerbation:
    • Rationale: M.G. has a history of seasonal allergies and is currently taking Zyrtec as needed. Allergic rhinitis can contribute to asthma exacerbations, particularly in environments with allergen exposure.
  3. Chronic Obstructive Pulmonary Disease (COPD):
    • Rationale: While M.G. does not have a significant smoking history, her father had lung cancer and her maternal grandfather had COPD, raising her risk for pulmonary conditions.

Plan:

  1. Pulmonary Function Tests (PFTs):
    • To assess for any reversible obstructive airway disease, particularly in light of her symptoms at work.
  2. Referral to Pulmonologist:
    • For further evaluation, including consideration of occupational asthma and potential need for work-related modifications.
  3. Consider Trial of Inhaled Corticosteroids (ICS) or Short-Acting Beta-Agonist (SABA):
    • Depending on the results of the PFTs and further evaluation, a trial of ICS or SABA may be warranted to manage symptoms.
  4. Allergy Testing:
    • Repeat allergy testing may be necessary to identify specific triggers in her work environment.
  5. Patient Education:
    • Discuss the importance of avoiding known allergens and potential modifications at work to minimize exposure.
    • Educate about the potential for occupational asthma and the need for regular monitoring and follow-up.

Follow-up:

  • Reassess symptoms after initiating the treatment plan.
  • Follow up in 1-2 weeks or sooner if symptoms worsen.