HISTORY
CHIEF COMPLAINT
Respiratory distress.
HISTORY OF PRESENT ILLNESS
This is an established patient seen in the office by his regular physician due to increasing respiratory distress for the past 12 hours, unrelieved by his usual routine of Capoten. The patient has a long-standing history of severe bronchial asthma, hiatal hernia with reflux and hypertension. No history of nausea, vomiting or other symptoms.
PAST MEDICAL HISTORY
Illnesses: As indicated in the HPI.
Operations: None.
ALLERGIES: NONE.
Social history: The patient does not smoke or drink or use recreational drugs.
REVIEW OF SYSTEMS
Except as mentioned in the HPI, noncontributory.
PHYSICAL EXAMINATION
GENERAL: The patient is a relatively quiet 56-year-old gentleman who appears in moderate respiratory distress with some intercostal retraction.
VITAL SIGNS: Blood pressure: 170/100. Respiratory rate: 26. Temperature: 97.2. Heart rate: 135.
HEENT: The mucosae are clear.
NECK: The neck is supple. No adenopathy is present.
CHEST: Heart: S1 and S2 are present in all areas without gallops, rubs or murmurs. Lungs: There are diffuse expiratory and inspiratory rhonchi without rales.
ABDOMEN: The abdomen is soft and nontender without evidence of hepatosplenomegaly. The bowel sounds are hypoactive.
RECTAL: Exam deferred.
EXTREMITIES: No clubbing, cyanosis, edema or calf tenderness.
NEUROLOGIC: The deep tendon reflexes are normoreflexive and equal bilaterally without evidence of pathologic reflexes.
IMPRESSION
1. Severe persistent asthma, status asthmaticus.
2. Hypertension.
3. Supraventricular tachycardia.
PLAN
Admit to Weston Medical Center and begin treatment with intravenous steroids, verapamil 80 mg q.12 h., bronchodilators, Tagamet 300 mg q.h.s., Mylanta. PA and lateral chest, EKG, arterial blood gases, electrolytes, SMAC-20. Oxygen per nasal cannula.
ICD-10-CM:
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