1.

Patient Information

Name : Lopez, Jason

Address : Brgy. Estefania, Bacolod City
Age : 20 yo
Sex : Male
Date of Birth : December 5, 2000
Civil Status : Single
Educ. Attainment : Second year college student, BS in Nursing
Occupation : NA
Religion : Baptist

1. Other Information

No. of Dependents : None

Date of Admission : August 14, 2022
Chief Complaints : difficulty of breathing and productive cough
Admitting Diagnosis : Bronchial asthma
Attending physician : Dr. Panez

Health History
Jason used to be frail and thin when he was a child and would experience seasonal mild to moderate asthma attacks
during his elementary years. Growing up, he was bullied for being weak by his peers which made him shy away from
sports/ physical activities and focus more on his academics. When he reached college, he wanted to improve his physique
to gain more confidence so he got himself a gym membership with the intention to bulk up and joined a hiking club to
boost his physical endurance.
Jason is a non-smoker and drinks alcoholic beverages on rare occasions only. His mother is also asthmatic while his
father reportedly does not have any preexisting diseases/illnesses. He has many allergies as a child (dust, cow’s milk,
seafood, and NSAIDs) which is why he is particular about his hygiene and food & drug choices.

History of the Present Illness

Jason just came from a 2-day hike and he felt like he is about to get the flu since he is having some muscle weakness and
occasional sneezing. However, he dismissed his symptoms as just muscle soreness and mild allergy brought by the
previous hike. 2 hours prior to admission, Jason was in the gym on his 1st day of membership and decided to join the
cross fit training class for the first time to “sweat his body weakness away”. After the 30-minute continuous training, he
was already out of breath and so he sat on a bench in a small garden just outside the main gym to rest and to get some
fresh air. There he met a friend who was with her pet dog. He petted and played with the dog while they were talking. Not
long after, he felt like his chest was slowly tightening up and was already coughing as he was having difficulty breathing.
He reached for his bag to get his rescue inhaler but he, unfortunately, left it at home. His friend decided to bring him to the
nearest Emergency Room/OPD for help when she noticed that he is already wheezing.

IV infusions : IVF bottle # 1 PLR 1L at 80cc/Hr 15cc/hour

to follow IVF#2 IVF D5NM 1L at 80cc/hr
Oxygen : With O2 at 3L/min via nasal cannula
Diet : NPO if dyspneic
Special Endorsement : With vital signs q Shift
Monitor RR q2hrs
Medications : Cefuroxime 750mg IVTT q 8hrs
Omeprazole 40mg IVTT OD
 Hydrocortisone 100mg IVTT q 8hrs
Prednisone 1tab q 12hrs DC.
With stat meds:

1. Salbutamol + Ipratropium 1neb q 15mins in 4 doses then q6hrs.

2. Hydrocortisone 200mg IVTT as single dose