Chamberlain College of NursingNURSING nr 603NR 603 WK 2 PART 2

Document Content and Description Below

Running head: WEEK 2 CASE STUDY SUMMARY Week 2 Case Study Summary Sara Martinez Chamberlain University NR 603: Advanced Clinical Diagnosis and Practice Across Life Span January 2019 2 WEEK 2 CA... SE STUDY SUMMARY Soap Note Patient Information: M.G., 40-year-old female, race unknown, insurance unknown. (S) 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): "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. Current Medications: Multivitamin Zyrtec Allergies: Strawberries-Rash; erythromycin- severe GI upset. PMHx: Michelle G. reports her overall health as good. 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. Past Surgical History (PSurg Hx) : Tonsillectomy, Cholecystectomy Childhood Illnesses: eczema as a child Immunization Hx: up-to-date on all vaccinations. Other Screenings: Not reported. Social History (Soc Hx) : 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. 3 WEEK 2 CASE STUDY SUMMARY Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20's. Denies illicit [Show More]

Last updated: 1 year ago

Preview 1 out of 12 pages