Patient Admission Note
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:
Medications:
Allergies:
Family History:
Social History:
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:
Asthma exacerbation.
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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