PATIENT NAME: LEBRON, VANESSA
DIAGNOSIS ON ADMISSION: Status asthmaticus
CHIEF COMPLAINT: The patient is a 16-year-old female who was
brought to the emergency room last night secondary to status
asthmaticus, shortness of breath, difficulty breathing, and
asthma exacerbation. She was seen in the emergency room with
significant respiratory distress, hypoxia with low O2
saturations, increased work of breathing, and bilateral diffuse
wheezing. History is given by herself, who is an adolescent
patient.
HISTORY OF PRESENT ILLNESS: She did develop cold two to three
days ago, and she continued to take her medications, which were
Xopenex nebulizer treatment as well as Advair inhalations b.i.d.
She says despite this, she started to have a lot of difficulty in
breathing yesterday in the afternoon and despite taking
treatments, it got worsened and that is why she was brought to
the emergency room.
PAST MEDICAL HISTORY: This is one of her multiple admissions in
the last few months. She was admitted for three days last month
secondary to asthma exacerbation. At that point, she had a
history that she ran out of her Advair and medications, and she
did not have any insurance at that point, and she was waiting for
her father’s insurance to be changed on 08/01. History this time
is that she developed cold and that caused asthma exacerbation.
In the emergency room, she was hypoxic; she received oxygen and
nasal cannula at 4 L/min with improvement in the O2 saturation.
She received a bolus of prednisone by mouth and neubulizer
treatment of albuterol and DuoNeb multiple times. The first
time, the albuterol treatment was continuous nebulization for one
hour; despite she continued to have increased work of breathing
and bilateral wheezing, with requirement of oxygen, for which she
is admitted for further management. Last night, the nurse called
me that she was very tight and hardly moving air. At that point,
we gave her another bolus of IV Solu-Medrol 2 mg/kg, which did
improve her status. On admission, we have started her on IV
Solu-Medrol 2 mg/kg divided into 4 doses every 6 hours, and also
we started Xopenex nebulizer treatment initially q.4h. Last
night, we continued the treatment q.2h and then p.r.n. She also
had temperature of 99.9 degrees, so I started her also on
Rocephin 1 g b.i.d. At this point, on this treatment, she is
improving. Her oxygen level is decreased to 2 L/minute. Her
work of breathing is improved. She is still on 2 L/minute with
O2 saturation of 96% to 97%.
ALLERGIES: THERE ARE NO KNOWN ALLERGIES.
FAMILY HISTORY: Negative.
SOCIAL HISTORY: Negative.
REVIEW OF SYSTEMS: As above. There is no diarrhea and no
vomiting.
PHYSICAL EXAMINATION:
VITAL SIGNS: Her respiratory rate is in high 20s to low 30s.
Her heart rate is in 130, which is tachycardia for her.
GENERAL APPEARANCE: She is afebrile. No heart murmur.
LUNGS: Still have bilateral wheezes, although the air exchange
is a little better and her work of breathing is improving with
decrease in use of accessory muscles to breathe.
ABDOMEN: Soft.
NEUROLOGIC: Grossly normal.
PLAN OF TREATMENT: As per orders. We will continue the IV Solu-
Medrol and Xopenex and DuoNeb treatments q.4h., and I will start
incentive spirometry because she does not breathe that deep to
improve the lung function a little bit, and if she continues to
improve by tomorrow, I will start to decrease the treatment
accordingly. She will be referred to a pulmonologist this time
because this is the third admission, and she has not been either
complaint with her medications, as she needs more than what we
had sent her home with. She went home on Advair, which is
steroid inhalation as well as bronchodilator inhalation with
Xopenex nebulization treatments. I spoke with her, discussed the
plans with her, and she voiced her understanding.
AAMERA N. AHMED, M.D.
ANA/ATL
DD: 08/16/2007 18:13
DT: 08/17/2007 11:355
