Case Study:
Present Illness
Mrs. Jones is a 56-year-old Caucasian female who recently moved to Arizona from Minnesota and is a new patient. She has been feeling tired lately, which she attributes to her allergies. She has been taking Claritin®, but for the past month, it has not been working well. She complains of a runny nose that is worse in the morning, associated with sneezing and an itchy throat. She also complains that her breathing is more difficult. She becomes dyspneic on minimal exertion and can hear herself wheezing throughout the day. She reports using the albuterol inhaler more frequently than every 4 hours. Her productive morning cough seems worse, but the color of her sputum has not changed. She denies discolored nasal drainage, headache, facial pain, loss of appetite, chest pain, edema, and fevers.
Medical History
Chronic obstructive pulmonary disease (COPD) and seasonal allergies; complaining of recent inability to sleep through the night
Family History
Her family history is noncontributory.
Medications
Claritin® 10 mg q am and Albuterol MDI 2 puffs q 4 hours prn.
Allergies
Seasonal
Social History
Smoked 2 packs per day for 30 years; quit 2 years ago.
Physical Examination
This is a w/d, w/n who is appropriate and cooperative. Vital signs are: Bp 128/72, pulse 88 and regular, respirations 20. She has dark circles under both eyes (allergic shiners), lungs have bilateral basilar wheezing, heart is regular without murmurs, abd is soft, nontender, and BS present.
Labs
O2 saturation 92% at room air at rest; spirometry reveals FEV1 = 45%, FEV1/FVC = 65%.
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