HPI: Ms. Jones is a pleasant 28-year-old African
Subjective American woman who presented to the clinic with
complaints of shortness of breath and wheezing
CC:"hard to take in air. My chest feels all tight and following a near asthma attack that she had two
I've been wheezing... I've had to use my inhaler a lot, days ago. She reports that she was at her cousin’s
and it doesn't feel like it's totally working." house and was exposed to cats which triggered her
asthma symptoms. At the time of the incident she
HPI: notes that her wheezes were a 6/10 severity and her
Onset: 2 days ago at her cousin's house after shortness of breath was a 7-8/10 severity and lasted
exposure to cats which exacerbated her asthma and five minutes. She did not experience any chest pain
reported symptoms. or allergic symptoms. At that time she used her
albuterol inhaler and her symptoms decreased
Location:Chest although they did not completely resolve. Since that
incident she notes that she has had 10 episodes of
Duration: "Minute or two" for each episode reported wheezing and has shortness of breath approximately
with a total of 10 episodes in last 2 days per patient. every four hours. Her last episode of shortness of
breath was this morning before coming to clinic. She
Characteristics/Quality: Tightness, feelings of not notes that her current symptoms seem to be
being able to take in air. worsened by lying flat and movement and are
accompanied by a non-productive cough. She
Aggravating factors/Associated Symptoms: Cats, awakens with night-time shortness of breath twice
dust, running up a flight of stairs. Worse upon per night. She complains that her current symptoms
exertion and when lying down flat. are beginning to interfere with her daily activities and
she is concerned that her albuterol inhaler seems to
Relieving factors: Proventil inhaler, resting be less effective than previous. Currently she states
that her breathing is normal. Diagnosed with asthma
Treatment/Medications/Remedies:Proventil Inhaler, at age 2.5 years. She has no recent use of
three puffs every 4 hours for past 2 days. Albuterol spirometry, does not use a peak flow, does not
90mcg/spray MDI record attacks, and does not have a home nebulizer
or vaporizer. She has been hospitalized five times
Severity:7-8/10 for asthma, last at age 16. She has never been
intubated for her asthma. She does not have a
FH:Sister with asthma current pulmonologist or allergist.
SH:Supervisor at Mid-American Copy & Ship, Social History: She is not aware of any
currently lives with mother and younger sister. environmental exposures or irritants at her job or
home. She changes her sheets weekly and denies
MH:States having all the required "shots they give dust/mildew at her home. She uses a hypoallergenic
you when you're a kid." Hospitlized as a child and pillow cover and her mattress is one year old. She
teen for asthma. ED a few months ago for foot injury denies current use of tobacco, alcohol, and illicit
that has since healed. drugs. She did smoke marijuana for 5 or 6 years, her
last use was at age 21 years. She does not exercise.
Updates to Meds: No updates. Previous medications
continued. Review of Systems: General: Denies changes in
weight, fatigue, weakness, fever, chills, and night
Updates to Allergies: Updated to include seasonal sweats.
allergies/hay fever along with cats & dust • Nose/Sinuses: Denies rhinorrhea with this episode.
Denies stuffiness, sneezing, itching, previous allergy,
ROS epistaxis, or sinus pressure.
General/Constitutional: No weigth loss, fever, chills, • Gastrointestinal: No changes in appetite, no
weakness reported. Patient does report fatigue upon nausea, no vomiting, no symptoms of GERD or
exertion that subsides at rest. abdominal pain
• Respiratory: Complains of shortness of breath and
Respiratory:"Been hard to take in air". Chest cough as above. Denies sputum, hemoptysis,
tightness & wheezing. pneumonia, bronchitis, emphysema, tuberculosis.
She has a history of asthma, last hospitalization was
age 16, last chest XR was age 16.
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