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 her asthma. She does not have a current pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. •
diagnosed at 2.5 years old Denies surgical history This last pap smear a few years ago Last tetanus booster was one year ago Patient states she is up-to-date on immunizations Social history: Patient is a single African American female who is a supervisor at Mid American ship, pursuing her bachelor's degree in accounting. Spends free time reading, attending talks at church, and watching television Denies tobacco use Patient states she consumes up to four drinks when in Social Gatherings but usually does not drink throughout the week Patient states uses her seatbelt whenever in her car Family history: Mother is currently alive and suffers from hypercholesterolemia and hypertension Father died at age 58 in a car accident Paternal grandfather is deceased suffered from colon cancer, hypertension, hypercholesterolemia, and diabetes Paternal grandmother is currently alive has hypertension and hypercholesterolemia Maternal grandfather is deceased suffered from hypercholesterolemia and hypertension Paternal grandmother died at age 73 from a stroke suffered from hypertension and hypercholesterolemia Brother is alive age 25 and is described as being overweight Sister is each 14 and suffers from asthma Review of systems: Constitutional: positive for fatigue. Patient denies weight loss, fever, chills, and weakness HEENT: positive for blurred vision when reading. Patient denies visual loss, double vision, hearing loss, sneezing, congestion, or dentition issues. Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.
skin: positive for dry skin. Patient denies rash or itching.
- Fall '15