week2respiratoryshadowhealth.docx - Ms. ago.Ms. expos

week2respiratoryshadowhealth.docx - Ms. ago.Ms. expos

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Ms. Jones is a 28 year old well developed  African American Female who presents to  the office today complaining of increased  shortness of breath as well as increase use  and need of her inhaler that began two days ago. Ms. Jones has allergies to cats which  exacerbate her asthma and has had recent  exposure to 3 cats at her cousins, she also  admits to sensitivty to seasonal allergies as  well as dust. She admits to increased cough with wheeze but denies nasal drainage or a  productive cough. She does not take any  medications for her allergies other than her  Albuterol inhaler 90 mcg 2-3 puffs q4 hours  prn wheeze/sob, and over the counter  acetaminophen and advil prn for headache  and cramping. She does report having  increased shortnes of breath with increased  activty as well as when she is lying flat. Ms.  Jones sleeps with one pillow and has no  difficulty sleeping. Ms. Jones also presents  with an elevated blood glucose and admits  to non compliance with medicaiton and  regular glucose monitoring.  HPI: Ms. Jones is a pleasant 28-year-old  African American woman who presented to  the clinic with complaints of shortness of  breath and wheezing following a near  asthma attack that she had two days ago.  She reports that she was at her cousin’s  house and was exposed to cats which  triggered her asthma symptoms. At the time  of the incident she notes that her wheezes  were a 6/10 severity and her shortness of  breath was a 7-8/10 severity and lasted five  minutes. She did not experience any chest  pain or allergic symptoms. At that time she  used her albuterol inhaler and her  symptoms decreased although they did not  completely resolve. Since that incident she  notes that she has had 10 episodes of  wheezing and has shortness of breath  approximately every four hours. Her last  episode of shortness of breath was this  morning before coming to clinic. She notes  that her current symptoms seem to be  worsened by lying flat and movement and  are accompanied by a non-productive  cough. She awakens with night-time  shortness of breath twice per night. She  complains that her current symptoms are  beginning to interfere with her daily activities and she is concerned that her albuterol  inhaler seems to be less effective than  previous. Currently she states that her  breathing is normal. Diagnosed with asthma  at age 2.5 years. She has no recent use of  spirometry, does not use a peak flow, does  not record attacks, and does not have a  home nebulizer or vaporizer. She has been  hospitalized five times for asthma, last at  age 16. She has never been intubated for 
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