CHIEF COMPLAINT (C/C)
“I have trouble breathing”
HISTORY OF PRESENT ILLNESS (HPI)
24-year-old single,domicile, Hispanic female presents to the Clinic with complain of difficulty breathing times 3 days. She reported her symptoms began with her having what she considered a common cold 3days,ago andworsened over the next 2 daysresulting in persistent cough, wheezing, chest tightness, increased dyspnea, and severe anxiety. Patient report that walking up the stairs to her bedroomor doing any type of activity worsen her SOB and chest tightness.
She denies any fever or chills, she denies chest pain but report wheezing accompanied by chest tightness and dyspnea. She denies headache nasal or sinus congestion. She reports drinkinghot tea andusing an old albuterol pump she had at home with little or no relief. Patient report history of childhood asthma but has not experienced an attack or symptoms in the last sixyears and reports never having experienced this level of severity of symptoms. She denies any know triggers, denies having any pets at home or exposure to cat dander, dust mites or grass or tree pollens.
PAST HISTORY
CHILDHOOD ILLNESSES:
Denies chickenpox measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine
Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018
– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2
HPV Three dose Series completed 2008
Influenza 10/21
COVID vaccine Completed 1/14/21, 2/7//21 and booster dose 9/18/21
ADULT ILLNESS:
Asthma
PSYCHIATRIC ILLNESS:
Denies past or present psychiatric illnesses.
ACCIDENTS or INJURIES:
Denies accidents or injuries
OPERATIONS: Denies
ALLERGIES: No known drug or food allergies.
MEDICATIONS:
Albuterol Ventolin HFA 2 puffs Q 4-6 hours PRN
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY:
Maternal grandmother: Unknown deceased
Maternal grandfather: Unknown deceased
Paternal grandmother: Unknown deceased
Paternal grandfather: Unknown deceased
Mother Age 50 HTN
Father Age 52 Asthma
3 siblings/ sisters 21, 16, 8: No Known Medical problems
SOCIAL HISTORY
Education: High school diploma
Occupation: office administrator
Living situation: Lives with parents in private home
Financial: Employed and lives with her parents
Tobacco: None
Alcohol: Socially drinks wine one glass per month
Drugs: Smoke Marijuana occasionally 1 blunt every 3-4 months
Sexual history: Heterosexual, sexually active, one partner
Marital status: Single
Exercises: No formal exercise routine
REVIEW OF SYMTEMS
GENERAL: Well-nourished female, with normal height and weight, who denies fever, chills, body aches, fatigue, night sweats or any changes in sleeping pattern.
HEAD: Denies headache or head injury
EYES:
Denies wearing glasses or contact lens; last vision check,10 months ago; denies pain redness, excessive tearing, double vision, floaters, lost of visual field cataract or glaucoma.
EARS: Denies hearing loss, ringing in the ear’s, earaches, or ear infections.
NOSE AND SINUS: Report having running nose and nasal stuffiness three days ago. Denies hay fever, nose bleeds, sinus congestion, obstruction, change in the ability to smell. Sneezing postnasal drip or history of polyps.
MOUTH AND THROAT:
Denies, soreness, dryness. Pain ulcers, sore tongue, bleeding gums, pyorrhea, dental carries, sore throat, hoarseness, history of strep throat or recurrent sore throat or rheumatic fever.
RESPIRATORY: Reports nonproductive cough, dyspnea, wheezing, shortness of breath and chest tightness times three days. Used albuterol with no relief. Reports history of childhood asthma with last asthma attack 6 years ago. Denies hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Denies TB or exposure to TB. Last PPD done 10 months ago and was negative. No history of pneumonia or history of environmental exposure
CARDIAC: Denies chest pain, or palpitations, denies paroxysmal nocturnal dyspnea, denies orthopnea, edema, palpitations, hypertension, known heart disease, rheumatic fever, heart murmurs, rheumatic fever syncope or near syncope, pain in posterior calves.
GASTROINTESTINAL: Denies abdominal pain, trouble swallowing, heartburn, problem with
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