CHIEF COMPLAINT: The patient presents today with complaint of cough times approximately two weeks.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old healthy Hispanic female who presents today with a cough for approximately two weeks. Associated signs and symptoms; coughing spells and shortness of breath off and on. No fever. No nausea, vomiting, no chills, no night sweats, no pain in chest or throat. Cough is nonproductive.
PAST SURGICAL HISTORY:
1. C-section x1.
2. Laparoscopy for ectopic pregnancy.
CURRENT MEDICATIONS:
1. NyQuil for cough.
2. Halls cough drops.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient denies alcohol, tobacco or drug usage.
FAMILY HISTORY: The patient denies.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: BP 140/90, pulse 106, respirations 18, temperature 99.4, and pulse ox 96% on room air.
GENERAL: The patient is alert and oriented x3. No acute distress noted. The patient is nontoxic in appearance. The patient is ambulatory in the ED.
HEENT: Unremarkable.
NECK: Supple without lymphadenopathy. No JVD or bruits noted.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate, regular rhythm without murmurs, rubs or gallops.
ABDOMEN: Soft and nontender. Positive bowel sounds in all quadrants. No rebound, no guarding, no hepatosplenomegaly, no masses noted.
BACK: Negative CVA tenderness.
EXTREMITIES: 2+ pulses, all extremities. Full range of motion of all extremities. No ecchymosis, edema, erythema, clubbing, cyanosis noted.
NEUROLOGIC: The patient is alert and oriented x3. The patient has 5/5 strength in all extremities, 2+ deep tendon reflexes equal throughout extremities. Gross sensation intact.
SKIN: Warm and dry to touch.
X-RAY: Chest x-ray: Negative. No signs of disease or pneumonia.
EMERGENCY DEPARTMENT COURSE: The patient was given albuterol nebulizer x1. After nebulizer, the patient states she feels a lot better. The patient had chest x-ray.
MEDICAL DECISION MAKING: We feel at this time this patient is suffering from acute bronchospasms. Pulse ox is 96% on room air. We do not feel that she is suffering from a PE at this time. The patient does not have any risk factors to suggest a PE. She does not smoke, does not take birth control pills, does not live a sedentary lifestyle. The patient has not traveled long distance in the past two to three weeks. She has no history of blood clots.
DIAGNOSIS: Bronchospasms.
PLAN:
1. The patient was given a prescription for albuterol inhaler. The patient was instructed to use two puffs every four to six hours p.r.n. shortness of breath.
2. The patient was instructed to follow up with primary care physician on Tuesday, scheduled appointment.
3. The patient was instructed to return to ER for any changes.
DISPOSITION: This patient was discharged to home in stable condition.
