Admission Note for SOB, Asthma

DATE: .......

CHIEF COMPLAINT: SOB x .......... days/months

HISTORY OF PRESENT ILLNESS:

Onset -
Character -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
Nausea - , Vomiting - , SOB - , Sweating - , CP -

Similar symptoms before -
Intubated -
Sore throat -
Runny nose -
Fever/Chills -
Muscle aches -
Headache -
Heart racing - , Calf pain - , Ankle swelling -
PEF - usual, most recent

PND -, DOE -
Cough -
Claudication - , Blackouts -
Blurred vision -
Ligheheaded - , Dizzy -
Recent travel -
Abdominal pain - , Black/bloody stool -
Dysuria -

ER Tx given -

PAST MEDICAL HISTORY: (circle all that apply)
MI CAD HTN DM CHF
Catheterization -
Echo -
Stroke CA PUD PVD DVT COPD Asthma Gallstones

PAST SURGICAL HISTORY: (circle all that apply)
CABG Cholecystectomy Hernia GSW Hysterectomy

MEDICATIONS: (circle all that apply)
Albuterol PRN
Inlaled Steroid MDI
Oral Steroid

ALLERGY: NKDA

FMH: (circle all that apply)
Asthma CAD DM Stroke HTN CA

SOCIAL HISTORY: (circle all that apply)
 Independent NH Lives w spouse son daughter
Alcohol - no heavy occasional last drink
Smoker: no
Illicit drugs- no cocaine heroin marijuana
Occupational hx:

REVIEW OF SYSTEMS: unremarkable apart from the symptoms above

PHYSICAL EXAM:
VITALS:
SpO2 - Initial vitals-

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal

LABS:

N= L= B= INR- AG= LFT
Cardiac enzymes x 1- negative , Mg++ , TSH
BNpep - UA: , Lipids: LDL HDL
ABG:
Old CXR:
CXR:
Old EKG:
EKG on admission:

A R A R E P Q R S T
D R I I E E


ASSESSMENT:
- SOB due to
*Asthma exacerbation caused by URTI, allergen exposure, medication nonocompliance
*Bronchitis
*Pneumonia - no infiltrate on CXR

PLAN:
- Aerosols q 4 hr and PRN SOB
- Solu-medrol 40 mg IV q 6 hr
- O2 to keep SpO2 higher than 92% (SpO higher than 95% if CAD)
- CBCD, BMP in AM
- Sputum Gram stain, C+S
- Robitussin 10 cc PO q 4 hr
- Tylenol 650 mg PO q 4-6 hr PRN pain/fever
- Heparin 5000 U SQ BID
- Home meds - check the list and restart
- Azithromycine 500 po daily

Signature:


Published: 0211//2005
Updated: 12/30/2009