Ms. Fielders Case Summary Paper

Superior Essays
CC
Ms. Fielders is a 56-year-old female here today complaining of difficulty breathing.

HPI
The patient tells me her symptoms seemed to start out of the blue on Tuesday. She started feeling achy, had some chills, and had a fever to 103.5 degrees. Her appetite was decreased, but she did not have any vomiting or nausea per se. No diarrhea. She had a headache as well as a cough at that point. Through the next day, she developed a lot of chest congestion. She has had a lower fever since then at 101, and she has been coughing. She has a history of asthma and her breathing has gotten significantly worse. She uses Advair 250/50 one puff twice daily every day and albuterol only if needed. Typically, she does not use that on a regular basis.
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She does have a history of persistent asthma. I recommended for the patient to use her albuterol with a spacer to stay with that on a regular basis and then taper, as she is able. She will continue with her Advair twice daily. She was written for a Z-Pak take as directed for five days #1 with no refills. We did talk about the option of a chest x-ray though for now that would not change her management and it was not ordered. However, she knows to contact me if she wishes to proceed with that, especially if she is not feeling better, in which case it would be necessary. She was also written for prednisone 20 mg three p.o. daily for five days #15 with no refills. We talked about increasing fluids and rest, good hand hygiene to avoid new illness or spread to others. I did review with her the use and side effects of the medication and she is aware of what to watching for. She knows that if her symptoms do worsen acutely through the weekend, she will seek care immediately at the ER. She will contact me otherwise next week if she is not feeling better. She does voice understanding of these recommendations. All questions were answered in the office

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