Patient Admission Note

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Patient Name: Lawrence Orn
MRN: 123456789
Date of Admission: October 25, 2050
Attending Physician: Dr. [Your Name]
Consultants: None

Chief Complaint:

The patient presents with worsening shortness of breath and cough for the past three days.

History of Present Illness:

Lawrence Orn is a 39-year-old male with a history of asthma and seasonal allergies. He reports that his shortness of breath has progressively worsened over the last three days, associated with a non-productive cough and wheezing. He denies fever, chills, or chest pain. He has been using his rescue inhaler more frequently without significant relief.

Past Medical History:

• Asthma

• Seasonal allergies

• Hypertension (controlled)

Medications:

• Albuterol inhaler (as needed)

• Lisinopril 10 mg daily

Allergies:

• Penicillin (rash)

Family History:

• Mother with a history of asthma

• Father with hypertension

Social History:

• Non-smoker

• Occasional alcohol use

• Works as a software engineer

Review of Systems:

• Respiratory: Shortness of breath, wheezing.

• Cardiovascular: No chest pain or palpitations.

• Gastrointestinal: No nausea or vomiting.

• Neurological: No headaches or dizziness.

Physical Examination:

• Vital Signs: BP 130/85 mmHg, HR 88 bpm, RR 22 breaths/min, Temp 98.6°F, SpO2 92% on room air.

• General: Alert and oriented, in mild respiratory distress.

• HEENT: Clear nasal passages, no oropharyngeal edema.

• Respiratory: Decreased breath sounds bilaterally, wheezing on expiration.

• Cardiovascular: Regular rate and rhythm, no murmurs.

• Abdomen: Soft, non-tender, no distension.

• Extremities: No edema, capillary refill < 2 seconds.

Assessment:

1. Asthma exacerbation.

2. Possible viral bronchitis.

Plan:

• Administer nebulized albuterol and ipratropium bromide in the ER.

• Obtain a chest X-ray to rule out pneumonia.

• Start oral prednisone 40 mg daily for 5 days.

• Monitor vital signs and respiratory status.

• Consult pulmonary if no improvement in 24 hours.

• Educate the patient on asthma management and the importance of medication adherence.

• Schedule follow-up in 1 week.

Signature:

Dr. [Your Name], MD
Date: October 25, 2050

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