Medical Record Documentation of Asthma

Abstract

Name: Jason Barnard1 Date of birth: August 3, 19842 Drug allergies: None known3 Immunizations: Complete4 Monday, November 11, 1991 8 PM CHIEF COMPLAINT: Wheezing, getting worse. HISTORY: Just moved to town last month with mother after parental separation. Was with father over the weekend (1 hour away). Has had wheezing attacks in the past, which usually respond to albuterol inhaler. Did not have inhaler at father's house. Started with sneezing and coughing on Saturday. Wheezing began on Sunday, but was mild. Has gotten progressively tighter throughout the day, despite use of inhaler. Temperature 101°F this afternoon. Vomited just before coming and brought up fruit juiced mixed with mucus. Has eaten nothing; drank 2 glasses of juice all day. Urinated 2 hours ago and twice earlier today. PHYSICAL EXAMINATION: Alert but breathing with obvious labor. Temperature: 100.5°F orally. Pulse: 100/min. Blood pressure: 120/70. Weight: 55 lbs. Tympanic membranes: Shiny and clear. Nose: Swollen, reddened membranes with white mucus. Throat: Clear. Neck: Small anterior lymph nodes. Chest: Breathing at 40/mm with moderate suprastemal and intercostal retractions and prolonged expiration. Audible wheeze, with faint inspiratory and moderate expiratory wheezing on auscultation. No rales heard. Heart: Good sounds in regular rhythm without murmurs. Abdomen: Soft and nontender. IMPRESSION: Acute asthma, probably triggered by viral upper respiratory infection. PLAN: Albuterol by nebulizer: 0.5 mL (2.5 mg; 0.1 mg/kg) in saline.