Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170cm 89kg 140/
81
89 20 98.5 97% Medication: Penicilllin- rash/hives; as a child
Food: NKFA
Environment: Cats and dust- itchy wat
...
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170cm 89kg 140/
81
89 20 98.5 97% Medication: Penicilllin- rash/hives; as a child
Food: NKFA
Environment: Cats and dust- itchy watery eyes,runny nose, exacerbates
asthma
History of Present Illness (HPI)
Chief Complaint (CC) “Breathing problems” CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - for instance
"headache", NOT "bad headache for 3
days”. Sometimes a patient has more
than one complaint. For example: If
the patient presents with cough and
sore throat, identify which is the CC
and which may be an associated
symptom
Onset Diagnosed with asthma at age 2 and ½ years; exacerbation two days ago
Location Chest and lungs
Duration Two days ago. Episodes occurring approximately every 4 hours or “5 times a
day”
Characteristics SOB not well relieved by inhaler, DOE, wheezing, difficulty breathing while
lying flat, dry cough, waking at night due to SOB
Aggravating Factors Expsosure to cats and dust. Bursts of physical exertion “run up stairs to class.”
“Past couple of days, though it doesn’t seem like anything in particular is
causing it.”
Relieving Factors Pronventil inaler. “Once I use my inhaler it only takes a minute or two for my
breathing to go back to normal…that’s not what’s been happening recently ,
though.”
Treatment Proventil inhaler
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
Proventil 90mcg 2 inhalations Every 4 hours prn 25.5 years Asthma: wheezing, SOB
Tylenol 500mg 2 tablets po Every 6 hours prn PRN Headache
Advil 200mg 3 tablets po Every 4 – 6 hours prn PRN Menstrual cramps
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