Katherine Harris 16 year old female
5.5 ht, 165cm, 150lb 68.2kg
CC: cough and shortness of breath
1. How can I help you today: cough for the last 3 weeks getting worse. SOB when
walking to class at school. Stop and take break
2. Do you have any other symptoms or concerns we should discuss? No, runny nose
congestion for 3 weeks, congestion went away in a week,but cough continue
3. When did you first notice feeling SOB? 3 days now and it’s made me a little scared
4. Does anything make your SOB better or worse? Gets a little better when stop
walking and rest for a bit worse at night.
5. Does anything make your cough better or worse: not really, constant, getting worse
over past 3 days and seems worse at night
6. Are you coughing up sputum: Nope
7. Do you have any allergies?
8. Are you taking any prescription medications? Nope, still no prescriptions
9. Are you exposed to secondhand smoke: yes, dad. Lost job 3yrs ago, moved to older
building with cockroaches, neighbors smoke inside building, I always smell smoke
everywhere
10. Do you wheeze: Im not sure
11. Do you now or have you ever smoked or chewed tobacco: Nope
12. Has there been any change in your shortness of breath over time: the last few years, had
cough and SOB but it got better after a few days, this time lasting longer
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13. Do you have any pain or other associated symptoms with your cough: No pain, getting
out of breath and I think that it maybe related
14. What treatments have you had for your cough: nothing
15. Are you taking any over the counter herbal medications? No, nothing like that
16. Are your immunizations up to date: I assume so
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PROBLEM STATEMENT
16-year-old female presents with cough nonproductive and SOB for 3 days. SOB when walking
to class and worse at night and is unable to sleep due to coughing. The only child lives with
parents and dad smoke in-home and is exposed to secondhand smoke. Inspiratory/expiratory
wheezing, tachypnea, afebrile. History of coughing that resolved. No history of childhood
asthma, no recent infections.
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ABUTEROL NEBULIZER TREATMENT TRIAL
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Add COPD
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Answer B
Management Plan Requirement
1. Write an actual Prescription that is appropriate to final diagnosis
2. Include patient education regarding final diagnosis
3. Include patient education regarding prescribed medication(s)
4. Include a referral(s) as applicable
5. Does not post a SOAP note in the management plan section
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Good start for this week. Couple of areas you can consider are additional differentials and tests for
this patient. Review history and physical and consider what other diagnoses could be possible with
the symptoms. Think of infectious lung conditions. You have until Sunday to retake the ihuman if you
choose.
SECOND ATTEMPT
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