NR 603 Week 2 Case Discussion: Pulmonary Part One
& Two
PBL Case Discussion: Pulmonary Part One (graded)
Setting: A free medical clinic that provides health care for the underinsured.
Part 1: The days at the free clinic are always full. People have waited patiently to get an appointment.
Your next patient, Cathy R., age 48, is a regular of the clinic. The chart states she is here for increased
difficulty breathing with exercise.
You enter the room and Cathy is standing up looking at a health poster on the wall. She warmly greets
you as you introduce yourself. You ask what brings her into the clinic today. “I’m so glad I could get this
appointment. I have had more problems breathing this spring than usual. Two months ago I was running
5 miles every day without any problems. Now I can barely run a mile. I am not wheezing, but I feel kind
of breathless and just don’t have the energy to keep running.”
HPI: Reports she has gotten over a spring cold that lasted over 2 weeks. She had lots of congestion and a
bad cough, which is resolving. It has been hard to catch her breath when running, even after using two
puffs of albuterol. No chest tightness but has not tried to run without using inhaler. She states her
endurance is low, and she has to push herself to keep running but ends up walking at least half of her
route that she used to run without difficulty. Her husband says she is snoring at night and she has woken
up once or twice in the past 2 weeks because of coughing.
PMHx: Cathy R. reports her overall health as good.
Childhood/previous illnesses: chickenpox and mumps as a child.
Chronic illnesses:
Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist 10 years ago, Took
allergy shots for 5 years with great results, now only takes Zyrtec when needed.
Surgeries: cholycystectomy, Cheilectomy right great toe.
Hospitalizations: childbirth x 3.
Immunizations: UTD on all vaccinations.
Allergies: erythromycin: severe GI upset.
Blood transfusions: none
Drinks alcohol socially, smoked for 10 years in her 20's; quit at age 35. Denies illicit drug use.
Sleeps 6 to 7 hours a night. Exercises 4 to 5 days per week.
Current medications: Multivitamin, Vit E (takes for hot flashes), CoQ10, fish oil, Zyrtec
, Social Hx: Married, lives with husband and 3 children and 3 dogs that sleep in their bedroom. Works as a
cashier at Walmart.
Family Hx: Children are healthy. Parents are deceased. Mother at age 51 from brain tumor, also had
breast cancer at age 32. Father died from lung CA, diagnosed when metastasized to brain. PGM: died
from pancreatic CA, PGF: Alzheimer’s, died at 82. MGM: died at 83, had HTN, atherosclerosis and many
heart attacks. PGF: dies at 71 from pleurisy.
Discussion Questions Part One:
What further questions do you have for Cathy at this visit?
What is your differential diagnosis list for this visit thus far with rationale?
Based on your differential diagnoses, identify what body systems you’d examine along with
pertinent positive/negatives in each system and any diagnostic tests you would like to perform?
C.R. 48 yo, F
S.
CC- increased difficulty breathing with exercise
HPI- 2 months ago she was running 5 miles daily without any problems. Now she can barely run
a mile without feeling breathless and loss of energy to keep running. Reports she has gotten over
a spring cold that lasted over 2 weeks. She had lots of congestion and a bad cough, which is
resolving. It has been hard to catch her breath when running, even after using two puffs of
albuterol. No chest tightness but has not tried to run without using inhaler. She states her
endurance is low, and she has to push herself to keep running but ends up walking at least half of
her route that she used to run without difficulty. Her husband says she is snoring at night and she
has woken up once or twice in the past 2 weeks because of coughing.
Additional Questions:
I don’t see Albuterol on your medication list, is it your medication? (Asthma)(COPD)
Do you experience any wheezing? Chest pain with coughing or breathing? (Asthma, Bronchitis)
Do you cough while you are exercising? (Asthma)
Any fever, chills or cough with sputum production? (Pneumonia).
How long would you say you have had your cough? (Bronchitis)
Has anyone else been sick? (Bronchitis, Pneumonia)
Did you have an allergy panel done when you used to go to the allergist? What were you allergic
to? Environmental Allergies? (Allergies, Pneumonia)
Does the shortness of breath come and go or is it continuous throughout the day? (Environmental
Allergic Reaction)
& Two
PBL Case Discussion: Pulmonary Part One (graded)
Setting: A free medical clinic that provides health care for the underinsured.
Part 1: The days at the free clinic are always full. People have waited patiently to get an appointment.
Your next patient, Cathy R., age 48, is a regular of the clinic. The chart states she is here for increased
difficulty breathing with exercise.
You enter the room and Cathy is standing up looking at a health poster on the wall. She warmly greets
you as you introduce yourself. You ask what brings her into the clinic today. “I’m so glad I could get this
appointment. I have had more problems breathing this spring than usual. Two months ago I was running
5 miles every day without any problems. Now I can barely run a mile. I am not wheezing, but I feel kind
of breathless and just don’t have the energy to keep running.”
HPI: Reports she has gotten over a spring cold that lasted over 2 weeks. She had lots of congestion and a
bad cough, which is resolving. It has been hard to catch her breath when running, even after using two
puffs of albuterol. No chest tightness but has not tried to run without using inhaler. She states her
endurance is low, and she has to push herself to keep running but ends up walking at least half of her
route that she used to run without difficulty. Her husband says she is snoring at night and she has woken
up once or twice in the past 2 weeks because of coughing.
PMHx: Cathy R. reports her overall health as good.
Childhood/previous illnesses: chickenpox and mumps as a child.
Chronic illnesses:
Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist 10 years ago, Took
allergy shots for 5 years with great results, now only takes Zyrtec when needed.
Surgeries: cholycystectomy, Cheilectomy right great toe.
Hospitalizations: childbirth x 3.
Immunizations: UTD on all vaccinations.
Allergies: erythromycin: severe GI upset.
Blood transfusions: none
Drinks alcohol socially, smoked for 10 years in her 20's; quit at age 35. Denies illicit drug use.
Sleeps 6 to 7 hours a night. Exercises 4 to 5 days per week.
Current medications: Multivitamin, Vit E (takes for hot flashes), CoQ10, fish oil, Zyrtec
, Social Hx: Married, lives with husband and 3 children and 3 dogs that sleep in their bedroom. Works as a
cashier at Walmart.
Family Hx: Children are healthy. Parents are deceased. Mother at age 51 from brain tumor, also had
breast cancer at age 32. Father died from lung CA, diagnosed when metastasized to brain. PGM: died
from pancreatic CA, PGF: Alzheimer’s, died at 82. MGM: died at 83, had HTN, atherosclerosis and many
heart attacks. PGF: dies at 71 from pleurisy.
Discussion Questions Part One:
What further questions do you have for Cathy at this visit?
What is your differential diagnosis list for this visit thus far with rationale?
Based on your differential diagnoses, identify what body systems you’d examine along with
pertinent positive/negatives in each system and any diagnostic tests you would like to perform?
C.R. 48 yo, F
S.
CC- increased difficulty breathing with exercise
HPI- 2 months ago she was running 5 miles daily without any problems. Now she can barely run
a mile without feeling breathless and loss of energy to keep running. Reports she has gotten over
a spring cold that lasted over 2 weeks. She had lots of congestion and a bad cough, which is
resolving. It has been hard to catch her breath when running, even after using two puffs of
albuterol. No chest tightness but has not tried to run without using inhaler. She states her
endurance is low, and she has to push herself to keep running but ends up walking at least half of
her route that she used to run without difficulty. Her husband says she is snoring at night and she
has woken up once or twice in the past 2 weeks because of coughing.
Additional Questions:
I don’t see Albuterol on your medication list, is it your medication? (Asthma)(COPD)
Do you experience any wheezing? Chest pain with coughing or breathing? (Asthma, Bronchitis)
Do you cough while you are exercising? (Asthma)
Any fever, chills or cough with sputum production? (Pneumonia).
How long would you say you have had your cough? (Bronchitis)
Has anyone else been sick? (Bronchitis, Pneumonia)
Did you have an allergy panel done when you used to go to the allergist? What were you allergic
to? Environmental Allergies? (Allergies, Pneumonia)
Does the shortness of breath come and go or is it continuous throughout the day? (Environmental
Allergic Reaction)
