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Original Question
05/02/2024 11:00 Author:Ellen Crandall, MD Location:Central Clinic Title:Establish Patient History and Physical Note: CHEIF COMPLAINT: “My asthma is acting up and I have missed too much school.” Ms. Kelly is a 20 yo woman who presents today complaining of increased shortness of breath, wheezing, poor exercise tolerance, and a head cold for 4 days. She began monitoring her peak flow rates twice a day and implemented an action plan that included albuterol nebulizations. However, she recently replaced her nebulizer machine and felt that it wasn’t working as well as her previous one. She notes that the time to complete her nebulizer treatments has increased from 6 to 8 minutes to 12 to 15 minutes with the new machine. PMH: Moderate persistant asthma for 12 years; she has been hospitalized twice in the past two years for asthma exacerbations and has been to the ED four times in the past 9 months. Perennial allergic rhinitis FH: Both parents living, mother 52 years old with HTN; father 58 years old with COPD(50 pack-year smoking history); one sibling age 24 in apparent good health. SH: No alcohol or tobacco use; sexually active for 2 years with the same boyfriend. Patient is a college sophomore history major and lives in a dormitory with her non-smoking roommate. Her boyfriend has a cat in his apartment. MEDS: Proventil HFA MDI 2 puffs PRN Azmacort MDI 3 puffs TID Beconase Inhalation Aerosol(nasal) 1 spray each nostril TID Albuterol nebulization 2.5 mg in 3 ml NS PRN Serevent
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