Subjective (S):

  • 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): M.G. is a 40-year-old female who reports experiencing intermittent shortness of breath (SOB), primarily while at work. She notes that her symptoms tend to subside by the time she gets home. She has not experienced SOB during weekends, but symptoms reappear a few hours after returning to work on weekdays. A few months ago, she had a similar episode at work that was severe enough to prompt her to leave work and seek care at an urgent care clinic. There, she received a breathing treatment (exact type unspecified) and was prescribed an antibiotic, which she completed. She is currently requesting another course of antibiotics as she believes her symptoms might be returning. She explicitly denies any sputum production, has not noticed any new allergy triggers, and does not experience heartburn. She does mention that her shortness of breath is generally worse during the spring season, correlating with her known seasonal allergies.
  • Current Medications:
    • Multivitamin: Taken daily.
    • Zyrtec: Taken as needed for seasonal allergies, with good effect.
  • Allergies:
    • Strawberries: Causes rash.
    • Erythromycin: Causes severe gastrointestinal upset.
Past Medical History (PMHx): M.G. describes her overall health as good. She has a history of seasonal allergies, which are particularly problematic during the spring. Ten years ago, she consulted with an allergy specialist and underwent five years of allergy shots, which she reports were highly effective. Currently, she manages her allergies with Zyrtec as needed.
  • Past Surgical History (PSHx):
    • Tonsillectomy: Performed during childhood.
    • Cholecystectomy: No complications reported.
  • Childhood Illnesses:
    • Eczema: She had eczema as a child, which has since resolved.
  • Immunization History:
    • M.G. is up-to-date on all recommended vaccinations.
Social History (Soc Hx): M.G. is married and lives with her husband and three children. Eighteen months ago, she was laid off from her job in advertising. To contribute to household finances, she took a job as a baker’s assistant at an Artisan Bread Bakery, where she starts her shift at 4 a.m. each day. She reports drinking alcohol socially, usually in moderation, and smoked one pack of cigarettes per week for three years in her 20s. She denies any use of illicit drugs. She typically sleeps 6 to 7 hours per night and maintains an exercise routine of four to five days per week.
  • Family History (Fam Hx):
    • Children: All are healthy, though one daughter currently has a sinus infection.
    • Mother: Deceased at age 80 from congestive heart failure.
    • Father: Deceased at age 82 from lung cancer that metastasized to the brain.
    • Paternal Grandmother (PGM): Died from unknown causes.
    • Paternal Grandfather (PGF): Died from a stroke at age 82.
    • Maternal Grandmother (MGM): Died at 83, had a history of hypertension, atherosclerosis, and multiple myocardial infarctions.
    • Maternal Grandfather (MGF): Died at 71 from complications of chronic obstructive pulmonary disease (COPD).
Review of Systems (ROS):
  • Constitutional: No reports of fever, chills, weight loss, or significant weakness. Reports contact with a sick individual (daughter with sinus infection).
HEENT:
  • Eyes: No visual loss, blurred vision, double vision, or yellowing of the sclera.
  • Ears, Nose, Throat: No hearing loss, nosebleeds, sneezing, runny nose, or sore throat.
  • Skin: Normal color, warm, dry, and intact. Turgor and capillary refill are brisk. No rashes, lesions, or itching reported.
  • Cardiovascular: No chest pain, pressure, discomfort, palpitations, or edema.
  • Respiratory: Reports shortness of breath primarily at work. Denies any cough or sputum production.
  • Gastrointestinal: Denies heartburn, anorexia, vomiting, diarrhea, change in bowel habits, or blood in stool.
  • Genitourinary: Denies dysuria, frequency, or pain with urination.
  • Neurological: No reports of dizziness, syncope, paralysis, ataxia, numbness, tingling, or changes in bowel or bladder control.
  • Musculoskeletal: No muscle pain, back pain, joint pain, or stiffness.
  • Hematologic/Lymphatics: No history of anemia, bleeding, bruising, or swollen nodes. No history of splenectomy.
  • Psychiatric: No history of depression, anxiety, or other psychiatric conditions.
  • Endocrinologic: No reports of sweating, cold or heat intolerance, polyuria, or polydipsia.
  • Allergies: Reports seasonal allergies, primarily during the spring. History of childhood eczema. No history of asthma.
This detailed case summary provides a comprehensive overview of the patient’s medical history, symptoms, and current condition. The emphasis is on understanding her respiratory symptoms within the context of her work environment and past medical history, which may guide further diagnostic evaluation and treatment plans