COMPLAINT: DOB
Birth history - prenatal, perinatal, postnatal
Unremarkable
Drainage, otorrhea
"None."
chief complaint:
Your patient today will be Donna Sagon.
Donna is an 16-year-old who is in the emergency department with
difficulty breathing. She is only able to speak in short sentences.
HPI:
"I'm having trouble breathing. It started a week ago, but it's not
getting any better. Today it is really bad. It gets a little better when
I take my inhaler, but now even that is not working very well. I've
been using it every few hours. It also seems to get a little better
after I shower. Any kind of walking or moving around makes it
worse, and it gets pretty bad when I try to sleep at night. This is as
bad as it has ever been. I really can't breathe well."
"It happens all the time. I have episodes of coughing and shortness
of breath almost every week. I've had bad attacks about three
times a year since I was a teenager. My chest feels tight and I can't
breathe. It's gotten worse since I moved to Ilang. When I was in
Nabunturan, it was pretty much the same year round. Exercise
definitely makes it worse. I've seen an allergist and a
pulmonologist."
past medical:
Lifestyle:
Exercise
"I get very little exercise."
Over-the-counter drugs: Laxatives, aspirin, cold
preparations, etc.
"No."
Animal contact/insect bites
"My roommate has a cat."
Diet
"I'm a vegetarian."
Alcohol
"I drink with my friends at night after work. On Saturday
nights we can get pretty carried away and drink a lot."
Tobacco
"I started smoking about 5 weeks ago. About a pack a day."
Travel
"I moved here from Los Angeles a few months ago. Otherwise, I
haven't traveled much in the last few years."
Average day, activities
"I'm a waitress. I party a lot at night after work. I can sleep in most
of the day."
Family unit, characteristics and history
"My mother and father are still married. I have one sister who is
two years younger than me."
Finances, especially for health care
"I don't have any insurance. I can't afford it. I only make about
$300 a week."
Home situation: Location, suitability, help
availability, transportation
"I live with a roommate. Neither of us has a car."
Occupational history
"I have been a waitress for the past two years."
Medical history:
Allergies [Medical History]
"I get a rash if I take penicillin or doxycycline. Codeine and
morphine make me dizzy. I'm allergic to grass and dust. My
allergist also told me I'm allergic to cockroaches."
Drugs, present medication, past medication, non-
medical uses
"I take an albuterol inhaler when I need it for my asthma. I've had
to take prednisone when I've had bad attacks in the past."
Family medical history
"My mother had a heart attack when she was 53. My aunt has
breast cancer. Otherwise, everyone is OK."
Health care professionals currently involved with the
patient
"I don't have a doctor here. I got the prescription for my inhaler
when I was in the ER about 3 or 4 months ago. I used to have an
allergist and a lung doctor when I lived in Los Angeles."
Immunizations
"I don't know what I've had. I think I received all the shots"
Past medical history including psychiatric, surgical,
previous lab
Asthma; allergic rhinitis; fusion of L4 L5 vertebrae.
Psychosocial:
Sexual history, including pregnancies
"I haven't had a boyfriend for the last 5 months. I've never been
pregnant."
Home situation: Location, suitability, help
availability, transportation
"I live with a roommate. Neither of us has a car."
Average day, activities
"I'm a waitress. I party a lot at night after work. I can sleep in most
of the day."
Family unit, characteristics and history
"My mother and father are still married. I have one sister who is
two years younger than me."
Review of systems:
Skin:
Rash
"None."
Redness, cyanosis, jaundice, or flushing [Skin]
"None."
Lymph:
Lymph gland enlargement
"I've always had some glands that I could feel in my neck."
Pain - Lymph Glands
"None."
Head:
Headache [Head]
"None."
Eyes:
Redness - Eyes
"Sometimes they get red and itchy."
Ears:
Drainage, otorrhea
"None."
Nose:
Nasal congestion
"Yes, it has been pretty stuffed for the past week."
Rhinorrhea or sinus congestion
"It's been running and my sinuses have been stuffed for a week."
Throat:
Sore throat
"I've had a sore throat for about a week."
Hoarseness, laryngitis
"None."
Circulatory:
Arrhythmia; heartbeat: fast, irregular, or palpitations
"Sometimes when I use my inhaler, I get palpitations."
Chest pain [Circulatory]
Respiratory:
Cough
"I cough almost every day. It is worse at night."
Respiratory problems (asthma, bronchitis, wheezing)
"I've had asthma since I was 17."
"None."Nocturnal dyspnea [Respiratory]
"I get short of breath at night."
Orthopnea [Respiratory]
"The shortness of breath seems worse when I lay down."
Sputum: consistency, amount, and color
"I'm not bringing up that much. What I do bring up is mostly clear."
Dyspnea, shortness of breath
"I've been short of breath for the past week, but it has gotten real
bad the last 3 days."
Chest pain [Respiratory]
"None."
Gastrointestinal:
Diarrhea
"None."
Abdominal discomfort or cramps
"None."
Appetite [Gastrointestinal]
"Normal."
Nausea and/or vomiting
"None."
Neurological
Anxiety, depression, feeling state [Neurological]
"None."
General:
Fever
"None."
Malaise
"None."
p.e:
Patient Appearance:
Donna 16 year old from Ilang is lying on a cart with her head elevated with
mild respiratory distress. She appears anxious and is only able to speak in
short sentences due to her distress.
Height: 5'9" (175.3cm)
Weight: 125 lbs (56.7kg)
vital signs:
Blood Pressure160/110 mm Hg
Heart Rate120
Temperature99.6° F (37.5 C)
Respiration30
Pulse120
O sat97%
2
Rhythmtachycardic
Height5'9" (175.3cm)
Weight125 lbs (56.7kg)
View|Nose
The patient's nose is symmetric. Nasal mucosa is pale, with a small
amount of clear discharge; the septum is midline; the turbinates
are slightly swollen and pale.
View|Mouth
Twenty-six teeth are present, several in both jaws having filled
cavities, and no active caries are noted; teeth are well-aligned and
occlusion is symmetric with slight overbite. Gums are pale red and
meet enamel margins of the teeth. Lips appear normal without
ulcers or cracking. Buccal mucosa is pink, moist, and without ulcers
or nodules. Hard palate is midline and moves symmetrically. Tongue
appears normal without coating. Pharynx is erythematous with no
exudate; tonsils are small and also without exudate.
Otoscope|Ear-Left
The patient's left ear canal is clear; the drum is intact, with a bright
cone of light in the pars tensa. The malleus is visible through the
drum. There are no concretions nor apparent thickenings in the
drum.
View|Chest
The chest is symmetric; the ratio of AP to lateral diameter is about
1:2.; breathing is tachypenic at 34 per minute, with great effort
and use of accessory muscles.
View|Abdomen-upperRight
On inspection, the abdomen is symmetric; skin is smooth and soft
without striae; venous pattern is minimal and there are no rashes.
The abdomen is scaphoid and symmetric without local bulges; no
peristalsis or pulsations are visible. The umbilicus is small, inverted,
midline, and without signs of inflammation or herniation.
Feel|Abdomen-upperRight
There is no tenderness on light or deep palpation. The gallbladder is
not palpable. The liver edge is palpable on deep inspiration; it is
smooth and non-tender. There is no referred pain or rebound
tenderness.
Stethoscope|Back-upperRight same lng sya sa mid
Listen to the breath sound.
Consultant:
Inspiratory and expiratory wheezes are readily heard in this
area. No other adventitious sounds are audible.
Stethoscope|Heart-Aortic
Listen to the heart sound.
Consultant:
The patient is tachycardic. The first heart sound is single and
normal in intensity. No murmurs are heard in systole or
diastole with the patient seated, supine, or in the left lateral
position.
labs:
Complete Blood Count with Differential (CBC w/diff)
WBC 6,700/mm 3
RBC 4.0 m/mm 3
Hemoglobin 10 g/dL
Hematocrit 31%
MCV 72 fL
MCH 26 pg
MCHC 31%
Platelets 285,000 /mm 3
Bands 5% WBC count
Neutrophils 57% WBC count
Lymphocytes 25% WBC count
Eosinophils 10% WBC count
Monocytes 2% WBC count
Basophils 1% WBC count
JP soap
Subjective
chief compliant: difficulty of breathing
with cough almost every week
history of asthma since 17 years old, three attacks per year
symptoms not improved with inhaler
symptoms got worst with exercise
symptoms got worst when moved to Ilang
symptoms gets better after getting shower
roommate has a cat
smoke 1 pack a day for 5 weeks
allergic to grass and dust, penicillin or doxycycline and cockroaches
takes albuterol inhaler for asthma and take prednisone if with attacks
has allergic rhinitis; fusion of L4 L5 vertebrae
Objective
appears anxious and is only able to speak in short sentences due to her distress
Blood Pressure160/110 mm Hg- hypertensive
Heart Rate120- tachycardia
Temperature99.6° F (37.5 C)- afebrile
Respiration30- tachypnea
Pulse120- tachycardia
O2 sat97%- normal
Rhythmtachycardic
the turbinates are slightly swollen and pale
Pharynx is erythematous with no exudate
breathing is tachypneic at 34 per minute, with great effort and use of accessory muscles
wheezing upon auscultation
Assessment data
bronchial asthma in acute exacerbation
Plan
admit patient
give albuterol inhalation 4-10 puffs by pMDI + spacer every 20 minutes for 1 hr.
give prednisolone 40mg 1 tablet once day for 5 days
oxygen therapy at 2L/min
position patient in sitting position
vitals signs every 4 hours
for maintenance: continue SABA albuterol, daily low-dose inhaled corticosteroid budesonide for
attacks
advise smoking cessation
avoid allergens like cats
for influenza and pneumococcal vaccination
encourage regular physical activity
