SAMPLE FOCUS NOTE
CHIEF COMPLAINT (C/C)
“I have trouble breathing”
HISTORY OF PRESENT ILLNESS (HPI)
24-year-old single, domicile, Hispanic female presents to the Clinic with complain of difficulty breathing times 3 days. She reported her symptoms began with her having what she considered a common cold 3days,ago andworsened over the next 2 daysresulting in persistent cough, wheezing, chest tightness, increased dyspnea, and severe anxiety. Patient report that walking up the stairs to her bedroomor doing any type of activity worsen her SOB and chest tightness. She denies any fever or chills, she denies chest pain but report wheezing accompanied by chest tightness and dyspnea.
She denies headache nasal or sinus congestion. She reports drinkinghot tea andusing an old albuterol pump she had at home with little or no relief. Patient report history of childhood asthma but has not experienced an attack or symptoms in the last sixyears and reports never having experienced this level of severity of symptoms. She denies any know triggers, denies having any pets at home or exposure to cat dander, dust mites or grass or tree pollens.
PAST HISTORY
CHILDHOOD ILLNESSES:
Denies chickenpox measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine
Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018
– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2
HPV Three dose Series completed 2008
Influenza 10/21
COVID vaccine Completed 1/14/21, 2/7//21 and booster dose 9/18/21
ADULT ILLNESS:
PSYCHIATRIC ILLNESS:
Denies past or present psychiatric illnesses.
ACCIDENTS or INJURIES:
Denies accidents or injuries
OPERATIONS: Denies
ALLERGIES: No known drug or food allergies.
MEDICATIONS:Albuterol Ventolin HFA 2 puffs Q 4-6 hours PRN
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY:
Maternal grandmother:Unknown deceased
Maternal grandfather: Unknown deceased
Paternal grandmother: Unknown deceased
Paternal grandfather: Unknown deceased
Mother Age 50 HTN
Father Age 52 Asthma
3 siblings/ sisters 21, 16, 8: No Known Medical problems
SOCIAL HISTORY
Education: High school diploma
Occupation: office administrator
Living situation: Lives with parents in private home
Financial: Employed and lives with her parents
Tobacco: None
Alcohol: Socially drinks wine one glass per month
Drugs: Smoke Marijuana occasionally 1 blunt every 3-4 months
Sexual history: Heterosexual, sexually active, one partner
Marital status: Single
Exercises: No formal exercise routine
REVIEW OF SYSTEMS
GENERAL: Well-nourished female, with normal height and weight, who denies fever, chills, body aches, fatigue, night sweats or any changes in sleeping pattern.
HEAD: Denies headache or head injury
EYES:Denies wearing glasses or contact lens; last vision check,10 months ago; denies pain redness, excessive tearing, double vision, floaters, lost of visual field cataract or glaucoma.
EARS: Denies hearing loss, ringing in the ear’s, earaches, or ear infections.
NOSE AND SINUS: Report having running nose and nasal stuffiness three days ago. Denies hay fever, nose bleeds, sinus congestion, obstruction, change in the ability to smell. Sneezing postnasal drip or history of polyps.
MOUTH AND THROAT: Denies, soreness, dryness. Pain ulcers, sore tongue, bleeding gums, pyorrhea, dental carries, sore throat, hoarseness, history of strep throat or recurrent sore throat or rheumatic fever.
RESPIRATORY: Reports nonproductive cough, dyspnea, wheezing, shortness of breath and chest tightness times three days. Used albuterol with no relief. Reports history of childhood asthma with last asthma attack 6 years ago. Denies hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Denies TB or exposure to TB. Last PPD done 10 months ago and was negative. No history of pneumonia or history of environmental exposure
CARDIAC: Denies chest pain, or palpitations, denies paroxysmal nocturnal dyspnea, denies orthopnea, edema, palpitations, hypertension, known heart disease, rheumatic fever, heart murmurs, rheumatic fever syncope or near syncope, pain in posterior calves.
GASTROINTESTINAL: Denies abdominal pain, trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching, burping, or passing of gas; denies constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Bowel movement 1-2 times daily, soft brown stool.
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PHYSICAL EXAMINATION
VITAL SIGNS: T 98.6 ºF, P68, RR 24, BP 126/70 (right arm, sitting, automatic), 126/68 (right arm, standing, automatic), oxygen saturation 94 % room air, height 5 ft. 6 in., weight 168 lbs. BMI 27.1.
GENERAL SURVEY: Alert and oriented x 3. Appears, fatigued, and anxious. She is slightly overweight, well-nourished, well-groomed and appears stated age of 24.
HEAD: Normocephalic, atraumatic, scalp clean, no dandruff, hair short, black, evenly distributed.
EYES:Symmetrical, lids without drooping or ptosis, sclera white, no icterus or muddy appearance, conjunctiva pale, corneal clear, PERRLA, EOM intact, light reflex direct and consensual brisk and intact. Visual acuity 20/20 bilateral. Optic disc with intact red reflex,optic discwith sharp margin, small central cup, and no edema. Retinal vessels intact, no A/V nicking or cotton wool spots.
EARS: Symmetrical and in line with the outer canthus of the eyes, manipulation of the pinna without tenderness. Ear canals clear, no cerumen observed, tympanic membrane pearly grey with good cone of light bilaterally. Acuity good to whispered voice. Rinne test AC>BC. Weber -midline
NOSE: Nares congested, with small amount of clear discharge; nasalseptum intact, turbinates’ slightly enlarged and boggy, Frontal and maxillary sinus non tender to palpation and percussion.
THROAT:
LIPS: dry, scaly, tongue midline, moist and without fasciculation; teeth in good repairs, no cavities; gum pink, no gingivitis, oral mucosa pink and moist, no halitosis. Tonsils without erythema and non-edematous, no injection or exudates; uvula midline and moves up and down with pronation.
NECK: Supple, FROM, Thyroid isthmus palpable, smooth, no nodules, mass, or tenderness. Trachea midline, no stridor, carotid upstroke brisk, no bruit. No JVD.
RESPIRATORY: Chest Anterior/Posterior thorax symmetrical, normal diaphragmatic excursion: Tactile fremitus diminished, in all lung fields; No tenderness on palpation of anterior and posterior chest. Percussion notes hyperresonance;Lungs with scattered wheezing in all lung fields no rales, rhonchi, or rubs.
CARDIOVASCULAR: No increase carotid pulsation on inspection No visible PMI; No palpable lifts, heaves, or thrill. PMI palpated at the 5 ICS, MCL; No carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; JVP-6 CM H2O. Heart sound one (S1) and heart sound two (S2) – normal; No S3 or S4; No murmurs, rubs, heaves, or gallops.
Abdomen: Protuberant, no scars. Bowel sounds active in all four quadrants; No abdominal guarding, or tenderness; Percussion notes tympanic in all four quadrants. No shifting dullness Liver span 5-6 cm dullness. No tenderness on light and deep palpation Liver, spleen, and kidneys non-palpable.
PROBLEM LIST
SOB
Chest tightness
Dyspnea
Wheezing
ASSESSMENT
Asthma Exacerbation
Differential Diagnosis
URI
Mild persistent asthma
Rhinitis
Sinusitis
Viral syndrome
COPD
DIAGNOSTIC PLAN:
Diagnostic
Pregnancy test
BMP, CBC
1) PFT
(2) Chest x-ray
Medication
Nebulized treatment albuterol 0.083% 1 dose via nebulizer stat
(1) Albuterol Ventolin HFA 2 puffs Q 6 hours PRN
(2) Medrol/ methylprednisolone dose pack as prescribe
REFERRAL:
Pulmonologist
Follow UP in 2 weeks:
PATIENT EDUCATION
You are being diagnosed with asthma exacerbation. Asthma is a chronic inflammatory disorder of the airways characterized by increased responsiveness of the tracheobronchial tree to various stimuli resulting in reversible narrowing and inflammation of the airways. Symptoms you make experience includes wheezing associated with cough, and sputum production, shortness of breath, chest tightness breathlessness and anxiety. Your asthma may be precipitated by cat allergen/dander, house dust mites ‘cockroaches as well as trees and pollen. Viral illness, such as in your case, can also induce airway obstruction.
You will continue to take your albuterol inhaler; this is your rescue medication. You will also start using another asthma medication which is a corticosteroid named Medrol, methylprednisolone dose pack. On day one, you will take 24 mg in four divided dose, every six hours. On day two, you will take 20 mg at the same time schedule of day one. On day three, 16 mg, On day four, 12 mg, On day five 8 mg and on the last day 4 mg.
I am referring you to a pulmonologist to follow up for a chest x-ray and spirometry testing to assess your lung functioning and vital capacity. Continue to exercise as tolerated. Hand washing is important to prevent exposure to additional cold/viruses. Continue your physical activity as much as you can tolerate.If you experience worsening or lingering symptoms, do contact the medical office, or call 911 immediately.