Respiratory model note.docx - Chief complaint Breatthing Problems not responding to inhaler Onset 2 days ago Location lungs Duration intermittent for

Respiratory model note.docx - Chief complaint Breatthing...

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Chief complaint: Breatthing Problems not responding to inhaler. Onset: 2 days ago Location: lungs Duration: intermittent for the past 2 days Characteristics: fishing States it feels like it's hard to take an error in that her chest feels tight and she has been wheezing. Patient states for albuterol MDI has been less effective over the past few days Aggravating factors: Patient states if she takes deep Inspirations this causes worsening cough. Patient states the more she moves around the more likely she is to cough. Patient states laying supine makes the symptoms worse Relieving factors: patient states rest helps with the symptoms Treatment: none reported Current medications: Albuterol MDI 90 mcg patient states she takes 2 to 3 Puffs every 4 hours as needed for shortness of breath Tylenol 500 mg po 1-2 tabs as needed for headaches Advil 200mg po 3 tablets as needed for menstrual cramps Patient states she was previously taking metformin unsure of dosage Allergies: Cats cause rhonorrhea, sneezing, and itching. Treats by avoiding cats. Also treats using inhaler if breathing problems occur and goes home to take a shower Dust causes sneezing, rhinorrhea, and wheezing during prolonged exposure Penicillin causes rash and hives patient states she avoids penicillin based medications for a doctor's advice Denies food allergies Past medical history: Diabetes diagnosed at age 24 Asthma 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
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  • Fall '15

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