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    Patrick Dycoco
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    A 19-year-old female patient presented to the emergency room with difficulty breathing. She had a history of asthma since childhood, experiencing attacks 3-4 times per year. On December 12th, she developed cough, wheezing, and dyspnea. She used her salbutamol inhaler with slight relief but had three severe asthma attacks that night, becoming pale and more short of breath each time. She was brought to the emergency room in respiratory distress and remained dyspneic even after multiple nebulizer treatments. The patient has a family history of asthma in her siblings and on both sides of her family. A physical exam found pallor, wheezing, and supraclavicular retractions

    Original Description:

    BRONCHIAL ASTHMA HISTORY AND PE

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    A 19-year-old female patient presented to the emergency room with difficulty breathing. She had a history of asthma since childhood, experiencing attacks 3-4 times per year. On December 12th, she developed cough, wheezing, and dyspnea. She used her salbutamol inhaler with slight relief but had three severe asthma attacks that night, becoming pale and more short of breath each time. She was brought to the emergency room in respiratory distress and remained dyspneic even after multiple nebulizer treatments. The patient has a family history of asthma in her siblings and on both sides of her family. A physical exam found pallor, wheezing, and supraclavicular retractions

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    © All Rights Reserved
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    10 views1 page

    Asthma

    Uploaded by

    Patrick Dycoco
    A 19-year-old female patient presented to the emergency room with difficulty breathing. She had a history of asthma since childhood, experiencing attacks 3-4 times per year. On December 12th, she developed cough, wheezing, and dyspnea. She used her salbutamol inhaler with slight relief but had three severe asthma attacks that night, becoming pale and more short of breath each time. She was brought to the emergency room in respiratory distress and remained dyspneic even after multiple nebulizer treatments. The patient has a family history of asthma in her siblings and on both sides of her family. A physical exam found pallor, wheezing, and supraclavicular retractions

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    Date of Interview: December 13, 2011

    Source of Information: Patient


    Reliability: 95%
    Source of Referral: None
    Identifying Data:
    Borer, Elma
    19 yrs old
    married
    Alang-alang Leyte
    Roman Catholic
    DOA: Dec 13, 2011/4 am, 1st admission
    Chief Complaint: Difficulty of breathing
    History of Present Illness:
    Dec 9, 2011
    Colds for 3 days
    No fever
    No meds taken
    Dec 12
    8pm
    Cough productive of whitish sputum,
    tspoon/cough
    Sorethroat
    Headache, PS of 2/10
    9pm
    Persistence of the above s/sx
    1st asthma attack: dyspnea, wheeze
    Dyspnea decreased in severity with sitting
    position, aggravated by supine position
    Sleeps leaning on the wall
    Salbutamol thru inhaler with slight decrease
    in severity of dyspnea
    Pt slept for 30 mins after taking salbutamol
    9:30pm
    2nd asthma attack, pallor
    Salbutamol
    11pm
    3rd asthma attack, pallor
    Increased in severity of dyspnea
    Salbutamol inhaled (last dose)
    Dec 13
    1am
    Due to consumed salbutamol, pt was rushed
    to the RHU for nebulization
    LOC upon arrival for 30 mins
    Nebulization was continued until the pt
    gained consciousness
    After 3 series of nebulization, pt was still
    dyspneic hence brought to EVRMC
    Past History:
    Childhood Illnesses: 5 years old, onset of asthma. 3-4
    attacks/ yr but had never hospitalized due to asthma.
    2-3 RHU visits/yr.

    Adult Illnesses:
    Medical: asthma attack every other month which
    usually lasting for 30 mins-1 hr . Such pattern started
    in highschool. 1 tab 400 mg ansinar, 1 tab 20 mg
    pred20, and salbutamol, all 2 x a day/attack
    Surgical: none
    Psychiatric: None
    Immunization: unrecalled. BCG scar at R deltoid
    Allergies: allergic to egg, chicken, shrimp, crabs, no
    known allergy to drugs
    Family History:
    Mother: 44 yo, healthy
    Father: 49 yo, healthy
    Siblings:
    1st: 23, f, no asthma, healthy
    2nd: 21, f, asthmatic
    3rd: pt
    4th: 17, F, asthmatic
    5th: 14, M, asthmatic
    6th: 11, M, asthmatic
    7th: 6, M, asthmatic
    Heridofamilial dses: asthma on both sides
    Personal and Social:
    Pt, 19 yo, housewife, highschool grad
    Husband, 24 yr, farmer, highschool grad
    Concrete house located ___meters away
    from the ricefield. With water sealed toilet
    and electricity. Water source is from a
    communal faucet not boiled prior to
    drinking. Cook with the use of firewood done
    inside the house. Household wastes
    collected by a garbage truck every week.
    House is clean, no dusts.
    No domestic pets
    Pt and husband are nonsmoker and
    nonalcoholic beverage drinker
    No exercise
    Usual diet: rice, fish, vegetable. Avoids
    foods like chicken, egg, milk, shrimp, crabs,
    Wakes up at 6am, sleeps at 9 am
    PE
    VS:
    temp 36.8
    RR: 34
    PR: 106
    BP: 110/80
    Pallor
    Supraclavicular retractions
    Wheeze in all lung field
    Apex beat at 6th ICS
    Heart beat is regular

    (-) murmur

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