Name: Alisha H.
MRN: 123456
DOB: 06/25/1984
Age: 28
CC: Periodic “chest tightness”
Subjective:
Patient is a pleasant 28 y/o Caucasian female with a history of asthma and anxiety. She presents today
with a history of atypical chest pain that has been periodic in nature which her PCP, Dr. D, has diagnosed
as asthma. Patient comes in today stating she wants “better control” of her asthma and to review the
results of her pulmonary function test from 7/12/12. Patient states that her first episode of chest pain
occurred approximately 10 years ago and went away after a short time without her doing anything. She
explains that since then she has periodically experienced similar episodes a couple times a month, often
worse in when it is very hot outside or when there are a lot of stressors in her life. On a weekly basis,
she states that she has two or three episode a week and experiences nocturnal coughing “a couple” of
times per month. She describes the chest pain as a “tightness” that limits her ability to “move air” and
denies radiation of the pain as well as wheezing or loss of consciousness. She also denies a correlation
between exertion and the episodes, but does say that she is unable to participate in normal activities
when she is having an attack. Patient states that the pain is a 7/10 during these episodes, but it is a
diffuse pain, rather than sharp or in any particular area. She says that time and consciously trying to
take deep breaths can help her recover from these episodes and that the pain is typically gone a couple
of hours after it starts. Patient denies experiencing heartburn. She has previously been prescribed
ProAir from her PCP and had PFTs performed approximately one year ago that showed a “borderline”
asthmatic pattern. Patient has not been satisfied with the effectiveness of ProAir.
Family Hx: Patient is married and lives with her husband and four year old son; Past family history is
significant for depression, diabetes mellitus and cardiovascular disease. Denies family history of lung
cancer, early COPD or asthma
Social Hx: Works as an account manager at a magazine; States she smoked approximately 1 pack of
cigarettes per day for 3 years but quit smoking 5 years ago; Also states she drinks approximately 1-2
drinks per month; Denies use of illicit drugs.
Allergies: Tetanus toxoid
Immunizations: Current
Medications: ProAir 180 µg (2 puffs) PRN; Propranolol 160 mg PO BID
PMH: Migraine headaches for which she sees a pain management doctor in York
PSH: Tubal ligation (2010)
Objective: Vitals: Temperature: 96.7F P: 76 R: 20 BP: 116/74 Height: 67 inches Weight: 183lbs.
BMI: 28.7
General Appearance: Pleasant, well groomed female; alert and oriented X3
Chest: No scars, ecchymosis, asymmetry or erythema of chest noted; Chest wall expansion found to be
equal, with no accessory muscle use or intercostal retractions noted; A:P ratio is 2:1; No tenderness or
fremitus of chest found on palpation; Lung fields are clear to percussion bilaterally; Dry breath sounds
found bilaterally in apices and bases; no wheezing/rales/rhonchi/stridor appreciated
Heart: RRR no m/g/r/
Skin: Warm, no erythema or cyanosis noted; No contusions, rashes, or bleeding
Peripheral Vascular: No edema of the upper or lower extremities noted; Radial and Dorsalis Pedis pulses
palpated, present and equal bilaterally, +2/4
Labs/Tests:
Pulmonary Function Test:
Spirometry: Prebronchodilator = moderate airway obstruction (FEV1/FVC = 61%)
Postbronchodilator = mild airway obstruction (FEV1/FVC = 78%)
Lung Volumes: TLC normal (91%), RV normal (99%)
Diffusion: DLCO normal (90%)
Assessment: 1) Asthma
2) Anxiety
3) Overweight
Differential Diagnosis: Vocal cord dysfunction, Gastroesophageal reflux, Tracheal and bronchial lesions,
Chronic Obstructive Pulmonary Disease
Plan:
1) Asthma: Due to the insufficient control of her symptoms with only an albuterol rescue inhaler
(ProAir), Mrs. H was prescribed Pulmicort 180 µg daily to help control her symptoms. She was
also given a renewal of her ProAir for use a rescue inhaler. If her symptoms do not significantly
improve she was instructed to inform the office. Mrs. H was scheduled for a follow up in six
months and at that time she will also get another set of PFTs. We also discussed talking with her
pain management doctor to possibly switching from Propranolol, a beta-blocker, to another
medication for her migraine headaches due to the adverse effect beta-blockers can have on
asthma.
2) Anxiety: We discussed breathing techniques to help her control her anxiety. Patient states that
she has been working with her PCP on her anxiety issues.
3) Overweight: Patient was given a handout, “Understanding Adult BMI” and we talked for 5
minutes about exercise and how she can use her albuterol inhaler to treat exercise-induced
symptoms if they arise.
Additionally, Mrs. H states that she receives an annual physical exam with her PCP that includes a pelvic
exam, Pap smear and lab work. Patient denied any additional questions and was informed to call our
office if she is not experiencing adequate control of her symptoms. In the event of a severe attack, Mrs.
H is to call 911 and see emergent care. Patient agreed to our plan and was scheduled to follow up with
our office in six months if no acute issues arise.
Vanessa G Wittstruck, PA-S
7/23/12
20:32