Example of Write-up

HPI: 14-year-old female with a history of mild intermittent asthma is brought in by her mother for increased wheezing, dyspnea, and occasional chest discomfort that are not being controlled with her current medication regimen. Patient states that she started having more difficulty breathing about one month ago, and it has progressively been getting worse. She describes the dyspnea as a “feeling like I can never take a deep enough breath in.” She started having to use her rescue Albuterol inhaler twice a week after gym class, but the frequency that she has been using it has steadily increased and she is now using it up to three times a day for the past week. She is also waking up during the night once or twice a week with dyspnea and must use her inhaler. Prior to one month ago, she was only using her inhaler occasionally, less than once a week, except when sick. Patient states that she never had the chest discomfort before these incidents started a month ago.

Her mother and the school nurse have also told her several times that they can hear her audibly wheezing. She often states that it feels as if “someone is sitting on her chest” when it becomes difficult to breathe. The chest discomfort is described as a pressure-like pain, located substernally. She denies any radiation of the discomfort. She rates the pain at a 4 out of 10 at the time, but currently rates the pain as a zero.

The wheezing, dyspnea and chest discomfort are all aggravated by any physical activity or exertion. She is often out of breath after walking up the three flights of stairs to get to her apartment. She denies any other triggers such as cold air, perfume, dust, or pollen. She does have seasonal allergies, but states that they are well controlled with medication and she has not had any symptoms of allergic rhinitis this season. She admits that her Ventolin inhaler helps alleviate the chest pain along with the dyspnea within a few minutes. She also has some relief of her symptoms by sitting forward in a tripoding position. She denies any associated fever, URI symptoms, headaches, cough, dysphagia, orthopnea, fatigue, weakness, palpitations, nausea, vomiting, diarrhea, sick contacts, dietary or lifestyle changes. She is unaware of any other associated symptoms.

She was diagnosed with mild intermittent asthma when she was 8 years old, but has never experienced symptoms with this frequency before. She was previously treated with her rescue Ventolin inhaler and has not been on any other medications for her asthma. She used to have an Asthma Action Plan and measure her peak flow readings at home, but states that she has not done this for the past three to four years. She has never seen a pulmonologist and her asthma medications have always been prescribed by her pediatrician. She has never required oral systemic corticosteroids for an asthma exacerbation. She has never had an Emergency Room visit, inpatient admission, or previous intubation for her asthma. She has never had a chest x-ray or undergone pulmonary function spirometry testing.

This is having a negative impact on the patient because she is more nervous to participate in physical activities. It is having a negative impact on her family as her mother is very concerned that she is having chest pains and think that there might be something wrong with her heart. The patient believes that her inhaler has stopped working, and was wondering if she could be given a “stronger inhaler” to better control her asthma symptoms.

 

 

PMH:

Generalized anxiety disorder, diagnosed in 2017.

Mild intermittent asthma, diagnosed in 2012.

Obesity, diagnosed in 2011.

Seasonal allergic rhinitis, diagnosed in 2009.

 

PSH: Patient denies any surgical history.

 

Medications:

Ventolin HFA 90mcg/puff inhaler 2 puffs inhalation every 4 hours as needed

Loratadine 10 mg 1 tab PO once daily

Patient is taking no other medications, including OTC, vitamin, or herbal medications.

 

Allergies:

Seasonal pollen allergies. Adverse reaction: rhinitis, nasal congestion, and cough.

No medication, food, or other environmental allergies known.

 

LNMP: March 22^nd, 2018.

 

Family History:

Mother: alive, age 34, has a history of type 2 Diabetes mellitus and morbid obesity

Father: alive, age 33, has a history of obesity

Brother: alive, 8, has a history of moderate persistent asthma

Brother: alive, 3, healthy

 

Social History: Patient lives at home with her mother and two younger brothers. She visits with her father every other weekend. She is a full-time student at Norwich Free Academy, and is doing very well academically in school. She does not participate in any sports or after school activities. She does admit to eating a lot of junk food and drinking 4 or 5 sodas every day. She was diagnosed with Generalized Anxiety Disorder last year, and sees a counselor through UCFS’s Behavioral Health Program. She denies any alcohol, drug, or tobacco use. She states that she has never smoked and no one in her house currently smokes. Patient is not in a relationship and has never been sexually active. She has a strong support system in her mother and close group of friends at school.

 

ROS:

General: no weakness or fatigue. Has gained 12 pounds in the past year.

Skin: no Denies rashes, lesions, changes in color, or itching.

HEENT:

Head: no Denies headaches, trauma or dizziness.

Eyes: no diplopia. Denies vision changes.

Ears: no Denies trouble hearing, tinnitus, vertigo or pain.

Mouth: no sores.

Neck: no swollen glands, pain or stiffness in neck.

Respiratory: See also HPI. No Denies cough or sputum production.

Cardiovascular: see HPI. No palpitations or peripheral edema.

Gastrointestinal: no hematemesis, hematochezia, trouble swallowing, heartburn, nausea, constipation, or diarrhea.

Urinary: no polyuria, hematuria, nocturia, or dysuria.

Musculoskeletal: no muscle or joint pain.

Neurologic: no changes in mood, paresthesia, vertigo, or syncope.

Psychiatric: no depression, or suicidal ideation. No history of eating disorders. Patient does have a history of anxiety and has had suffered anxiety attacks in the past.

Hematologic: no anemia or easy bruising.

Endocrine: no cold intolerance, polyuria, polydipsia, or sweating.

 

Physical Exam:

General: pleasant, well-groomed female, sitting comfortably on the exam table with no signs of anxiety, but some mild dyspnea at rest.

Vital Signs:

Height: 60 inches

Weight: 194 pounds

HR: 86 bpm

RR: 24 bpm

Temp: 98.2 degrees F

SpO2: 98% on RA

BP: 118/72 mmHg

Pain: 0/10

Skin: warm, dry, no suspicious lesions or erythema.

HEENT:

Eyes: visual fields full by confrontation. Conjunctiva pink, sclera white. EOMs intact. Pupils equal, round, and reactive to light. Disc margins sharp, without hemorrhages or exudates, vessels normal in appearance.

Mouth: oral mucosa pink and moist without lesions.

Neck: supple, trachea midline. No goiter or JVD.

Lymphatics: no lymphadenopathy.

Thorax and Lungs: thorax symmetrical with fair excursion. Breath sounds diminished throughout all lung fields with faint end expiratory wheezes bilaterally. Patient is able to speak in complete sentences, but is tripoding slightly. No rhonchi or rales heard. No retractions seen.

Cardiovascular: RRR. S1s2 heard. No rubs, gallops or murmurs.

Abdomen: abdomen soft, non-distended, non-tender to palpation. Active bowel sounds in all 4 quadrants. No masses or organomegaly noted.

Musculoskeletal: no joint deformities. Good range of motion in hands, wrists, elbows, shoulder, hip, knees, and ankles.

Neurological: no focal deficits. Alert and cooperative, sensory appropriate. Speech clear and fluent, thought content clear with no delusions and good eye contact. Oriented to place, person, and time. All CNs intact.

Extremities: calves supple, non-tender. Extremities warm, no clubbing or cyanosis.

Peripheral Vascular: No peripheral edema. All pulses 2+ and brisk.

Breast/ GU exam: deferred

 

No Laboratory Data Available

 

Assessment:

 

Problem List:

• Dyspnea on exertion
• Poor control of asthma symptoms
• Intermittent chest discomfort
• Obesity
• Allergic rhinitis
• Generalized anxiety

 

 

 

Differential Diagnoses:

• Poorly controlled exercise induced asthma: The patient has a history of asthma, but her symptoms have been increasing in severity and frequency over the past month. She reports that they are happening with exertion or physical activity, and denies any other triggers. All of her symptoms are relieved by her rescue Ventolin inhaler, but her asthma is obviously not well-controlled as she is using her rescue inhaler several times a day.
• Respiratory Infection: It is possible that the patient’s symptoms could be caused by a respiratory infection. She denies any recent illness or current URI symptoms, but she could be unaware of a sinusitis, allergic rhinitis, or bronchitis that could cause her to have audible wheezing and shortness of breath.
• Cardiac Failure: It is possible, although not likely, that the patient’s dyspnea, wheezing and chest discomfort can all be caused by cardiac failure associated with some type of undiagnosed congenital or acquired heart disease. The fact that this patient’s symptoms are intermittent and have been lasting for about a month make a cardiac cause less likely. There are no signs of cardiac disease on physical examination (tachycardia, gallops, or murmurs), but it is important to rule out a cardiac issue whenever a patient is complaining of chest discomfort.
• Gastroesophageal Reflux Disease: GERD can mimic asthma symptoms, as the refluxed stomach contents can be aspirated into the lungs causing dyspnea, wheezing, and chest discomfort. The patient’s chest discomfort can be attributed to heartburn caused by GERD as well. The patient’s obesity also makes a diagnosis of GERD more likely. However, the patient does not have any other symptoms such as nausea, belching, odynophagia, or dysphagia.
• Hyperventilation due to anxiety: Patient does have a history of anxiety and it is possible that she could be having shortness of breath due to hyperventilation during an anxiety attack. It would also be possible for her to have chest discomfort from hyperventilation due to anxiety. However, the patient states that her dyspnea and chest discomfort seem to usually occur with exertion. She has been working with Behavioral Health for a year on her anxiety and states that she has very few symptoms currently. She is aware of her triggers and anxiety symptoms, and it is unlikely that the symptoms would always be relieved so quickly with her rescue inhaler if they were purely caused by her anxiety.

 

Most Likely Diagnosis: Poorly controlled exercise induced asthma: The patient has had to use her rescue medication more and more, and is sometimes using it multiple times in one day. She is having nighttime symptoms as well a few times during the week, showing that her asthma is poorly-controlled and her treatment regimen needs to be adjusted. She has not had any follow-up on her asthma after her diagnosis 6 years ago. She has gained a considerable amount of weight in that time, especially in the past year, which could be contributing to her difficulty breathing. She also never had any baseline spirometry testing done. Her symptoms are all relieved by her rescue Ventolin inhaler, making it very likely that these symptoms are caused by bronchoconstriction. She has not been compliant with an Asthma Action Plan or peak flow meter readings either, making it likely that she is not treating her asthma properly.

 

Treatment Plan:

• Dyspnea on exertion: The patient is suffering from a fairly severe increase in dyspnea. She is using her rescue inhaler several times every day, with any type of exertion, and is mildly dyspneic today in the office with basic movement. It is unclear what has caused this recent increase in dyspnea, but it is clearly not being controlled with her current medication.
• Outpatient burst treatment of systemic corticosteroids is warranted giving the severity and frequency of her dyspnea. Patient is prescribed Prednisone 50 mg 1 tab PO once daily with food. Taper dose over 5 days.
• One week follow-up appointment is made today. If symptoms do not improve, will consider ordering a CXR to rule out other pulmonary etiology.
• Patient is instructed to continue using Ventolin inhaler as ordered for shortness of breath up to four times daily. She will also begin using Flovent inhaler twice daily as directed as well (Fluticasone inhaler 220 mcg/puff 2 puffs twice daily).
• If dyspnea becomes worse and the patient has increased difficulty breathing, she has been instructed to go directly to the Emergency Room.

 

• Poor control of asthma symptoms: Patient has not had a follow-up of her asthma for several years and stopped taking peak flow readings at home. It is evident that her asthma has evolved in this time period and she now needs to alter her routine.
• According to Asthma Classification Guidelines set by the National Asthma Education and Prevention Program, the patient has moderate persistent asthma and should be on a daily inhaled corticosteroid (ICS) with or without an additional long-term control medication. She is prescribed Fluticasone (Flovent) inhaler 220 mcg/puff 2 puffs twice daily.
• Will monitor response to new medication and consider adding a long-term control medication in the future if symptoms are not well-controlled on ICS. Will monitor this by the frequency with which she still needs to use her rescue inhaler.
• Spirometry should be done in order to properly diagnose degree of airway obstruction and the potential for obstruction reversibility with bronchodilator therapy. Pulmonary consult placed.
• Extensive patient and family education is needed. Patient is given education on recognizing triggers, proper medication techniques, self-monitoring with peak flow readings, and when to seek medical care. Patient is provided with an Asthma Action Plan that details how to take medications, how to alter medications in response to worsening asthma, and when to go to the Emergency Room. Patient is provided with a new peak flow meter and instructed on proper usage and the importance of compliance. Patient and mother verbalized their understanding.

 

• Intermittent chest discomfort: Patient is having chest discomfort that seems to correlate with her difficulty breathing. She was not noticed to have any irregularities on physical examination, and has no issues at rest. She has no known history of cardiac disease. However, it is important to rule-out any type of cardiac problems that could be contributing as an underlying cause of the chest symptoms due to the potential of devastating results.
• 12-lead EKG is ordered. Patient will need to go to the Outpatient Cardiology office at Backus Hospital in order to have this test preformed. She is provided with the order requisition slip needed.
• As patient shows no other signs of a cardiac problem, if EKG is normal, no further testing is required at this time. If EKG is abnormal, a Cardiology consult will be placed depending on the results.

 

• Obesity: Patient is obese and it is having a negative impact on her health, including her breathing. By being obese as a teenager, she is much more likely to be obese as an adult and at a greater risk of multiple health concerns.
• Lifestyle changes recommended. Patient is encouraged to join an athletic team or other regular physical activity. It is recommended that she engages in 30 minutes of cardio exercise per day, 5 days a week. She is given a log book to accurately keep track of her physical activity.
• Patient is consulted about proper dietary changes, including cutting soda out of her diet. Patient is provided with multiple resources on healthy eating choices and proper portion control.
• Follow-up appointment made for 3 months to check on weight. Patient set her goal to lose 1 pound every other week. If progress has not been made at the 3-month follow-up, will consider a referral to a Nutritionist.

 

• Allergic rhinitis: Patient has a history of allergic rhinitis and takes daily medication. She currently denies any symptoms related to her pollen allergies, and states that she has had no symptoms so far this season such as cough, rhinitis, or congestion. It is important for her to continue this routine as these symptoms could exacerbate her dyspnea and wheezing.
• Patient is instructed to continue taking Loratadine 10 mg 1 tab PO once daily as directed.
• Patient reeducated about the importance of compliance with medications, and what triggers and symptoms to be aware of in association with her asthma.

 

• Generalized anxiety: The patient has a history of generalized anxiety and has seen a counselor and a psychologist through Behavioral Health since last year. She states that her symptoms have improved immensely and she has developed many new ways of coping with things that used to trigger her anxiety attacks.
• Patient encouraged to follow-up with regular appointments with Behavioral Health to continue psychotherapy treatment.
• Educated patient and parent on alternate ways to cope with anxiety symptoms and stressors.
• Symptoms seem well-controlled at this time, would not recommend adding any other therapy or medication at this time.

 

Disposition:

• Patient is sent home with two new prescriptions and an order for an EKG. It is recommended that she go for the EKG and fill her prescriptions immediately in order to begin her new asthma routine ASAP.
• Pulmonary consult was made for further testing and treatment recommendations. Patient will receive a phone call concerning her appointment with the pulmonologist.
• Follow-up appointment is made for 7 days to check dyspnea and asthma symptoms, as well as compliance to medication and lifestyle changes.
• Follow-up appointment is made for 30 days for a weight check.
• Patient and mother are instructed to go to the Emergency Room immediately if symptoms worsen.