DATE OF ADMISSION: MM/DD/YYYY
MODE OF ARRIVAL: Walk-in.
CHIEF COMPLAINT: Asthma attack.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with significant past medical history of asthma, who presents with complaints of an asthma attack occurring two hours before his presentation. The patient notes that he began experiencing shortness of breath. He is currently out of his albuterol inhaler. The patient notes that this attack is very similar to his previous attacks, and there are no differentiating characteristics. The patient has been seen approximately six to seven times over the past nine months in this ER for asthma exacerbations. The patient notes that his last attack was approximately two months ago, and he has not been hospitalized for his asthma in a few years. The patient notes that he was intubated one time for his asthma; however, this was approximately (XX) years ago. The patient notes that he has been out of his Flovent and albuterol inhalers for a few days. He denies any fevers, sore throat or chills. He denies any cough or rhinorrhea. The patient denies any sinusitis symptoms. The patient notes that he has exacerbations in the fall generally as the weather changes.
PAST MEDICAL HISTORY: Asthma.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies any tobacco use. The patient notes occasional use of alcohol socially. The patient denies any illicit drug use.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Albuterol MDI.
2. Atrovent.
3. Advair.
4. Flovent.
REVIEW OF SYSTEMS: The patient denies any fever or weight loss. The patient denies any eye pain, diplopia or blurry vision. The patient denies any sinusitis or rhinorrhea, cough or congestion. The patient denies any chest pain, palpitations or dyspnea on exertion. The patient notes respiratory symptoms as per the HPI. The patient denies any nausea or vomiting. The patient denies any melena, diarrhea or constipation. The patient denies any frequency or urgency. The patient denies any rash or lesion. The patient denies any loss of consciousness, paresthesias, loss of coordination or weakness.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished (XX)-year-old Hispanic male who appears his stated age. He is alert and oriented x4 and in no apparent distress. He is pleasant and cooperative.
VITAL SIGNS: Pulse is 92 beats per minute with a blood pressure of 122/82 mmHg, respirations are 18 breaths per minute, oxygen saturation is 93% on room air, and temperature is 98.6 degrees.
HEENT: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Mucous membranes are moist. There is no erythema to the oropharynx or oral cavity.
NECK: Supple without lymphadenopathy.
CHEST: Expiratory wheeze, diffusely scattered across all lung fields with diminished breath sounds.
CARDIOVASCULAR: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. There is no rebound or guarding.
EXTREMITIES: There is no extremity edema noted. Peripheral pulses are adequate and equal in all four extremities. Warm and dry with no edema, cyanosis or clubbing.
DIAGNOSTIC DATA: Chest x-ray was obtained, which showed no acute cardiopulmonary disease. There was no infiltrate noted, and the lung fields were clear.
EMERGENCY DEPARTMENT COURSE: Upon arrival, the patient was triaged and placed in a bed. Vital signs were obtained, and a history and physical was performed. The patient was given DuoNebs x3 and given a 60 mg dose of prednisone orally. The patient was taken for a chest x-ray. Following the administration of his DuoNebs, the patient felt that he was returned to baseline. He was walked around the unit, and upon return was able to produce a peak flow of 360. The patient stated that he felt at his baseline and requested that he be able to leave the department. The patient was provided with education of acquiring primary care, including a clinic list, and also provided albuterol metered-dose inhaler. He was also given a script for albuterol and his Flovent. The patient stated that he had remaining prescriptions for his other asthma medications. The patient was then discharged to home. The patient remained hemodynamically stable throughout his entire ED course.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old Hispanic male with past medical history significant for asthma, including many exacerbations treated in this ER. He has recently been out of his medications and today presented with an acute exacerbation of his asthma. Given the patient’s response to therapy as well as a negative chest x-ray or history of cough that would be suggestive of pneumonia, it was felt that this can be handled without antibiotics. The patient will be continued on his prednisone burst and was provided prescription for such. The patient was also provided a prescription for the asthma medications that the patient is currently out of. He was counseled regarding the need to establish himself with a primary care physician and provided a clinic list. The patient voiced understanding of these instructions upon discharge.
DIAGNOSIS: Asthma exacerbation.
DISPOSITION: The patient will be discharged to home in good condition.
PLAN:
1. The patient is to follow up and establish a primary care physician and was provided with a listing of available clinics accepting new patients.
2. The patient was provided a prescription for prednisone and refilled his albuterol and Flovent prescriptions.
3. The patient was counseled on any signs or symptoms that would indicate a need to return to the ER.
The patient voiced understanding of this plan.
