CHARTING

CLINICAL HISTORY AND PHYSICAL EXAMINATION
Date:11/10/2020 Informant: Patient

Chief complaint: Shortness of breath
History of present illness: Patient was a 16-year-old male who had a history of asthma for 8 years, he
had been in his normal state of health until 7 days ago when he noticed that he’s been having a tightness
feeling In his chest and difficulty of catching his breath while walking, running and doing daily chores.
He used to do household chores and walk/jog 1 mile without experiencing any difficulty, but now he’s
experiencing shortness of breath after just walking 500 yards. Patient also said that his father smokes
inside or outside of the house that might be the cause of his difficulty of breathing Patient usually takes
albuterol inhaler when he had asthma attacks, he had no more medications over-the-counter medications,
or supplements taken aside from his inhaler. The patient also reported a 4 to 8-pound weight gain over the
past 6 weeks. Vital signs as follows: BP:130/80 RR: 30 HR: 78 SPO2: 87% TEMP 37°C
Weight gain/loss Colds Dysuria
Fever/Chills Difficulty of breathing Urinary frequency
Night Sweats Cough Flank pain
Body Malaise Hemoptysis Polyuria
Anorexia Chest pain Oliguria/Anuria
Pain Chest discomfort Nocturia
Pruritis Palpitation Hematuria
Rashes Orthopnea Urgency
Cyanosis PND Hesitancy
History of head trauma Easy Fatiguability Dribbling
Headache Exertional dyspnea Urinary incontinence
Dizziness Edema Pelvic/Inguinal pain
Loss of Consciousness Calaudication Vaginal/Penile Discharge
Seizure Dysphagia Menorrhagia
Visual Dysfunction Heart burn Amenorhea
Difficulty of Hearing Abdominal Pain Joint pain/stiffness
Tinnitus Abdominal enlargement Muscle cramps
Epistaxis Early Satiety Easily bruisability
Hoarseness Diarrhea Others:__________
Nausea/Vomiting Constipation _________________
Hematesis Melena/hematochizia
Name of Patient: Austin Vien C. Tulagan Hospital No.18-1505-819
Physicians Order Sheet and Progress Notes
Date, Time, And Progress notes Physicians Order/ Name & Remarks
Signature of Physician
(Time and Noted by the Nurse)
11/10/20 10A.M. Admit to observation status
Diagnosis: Allergic asthma
VS: Q 2hour x 2, then Q 4 hours and
prn (with pain assessment)
-Notify physician if O2 sat is less than
90% on current O2 therapy
Nursing: Call MD/PA for worsening
dyspnea or oxygen requirement and prn
Continuous Pulse
Oximetry Walk Test 4 hours after
admit, then every 4 hours. SAO2 before
and after 6 minute walk.
Diet: regular diet
Medications:
O2 via nasal cannula at 3 liters
Prednisone 60 mg po q8 hr;
Azithromycin 500 mg po x 1
Acetaminophen 650mg po q 4 hrs prn
for fever or pain
Nurses Notes
Date &
Time
11/10/20 F- Ineffective Breathing Pattern
3:00 P.M.
D – “Medyo hirap po akong huminga” using of accessory muscle to breath
noted, presence of non-productive cough, shortness of breath, increase
respiratory rate of 30 cpm.
A - Assessed and recorded respiratory rate and depth at least every 4 hours,
observed for breathing pattern, assessed for use of accessory muscles,
assessed for skin color, temperature, capillary refill; observe central versus.
peripheral cyanosis, place patient with proper body alignment for maximum
breathing pattern, stayed with the patient during acute episodes of
respiratory distress, Provided respiratory medications and oxygen, per
doctor’s orders, educated patient about pursed-lip breathing and
relaxation techniques, encouraged frequent rest periods and teach patient
to pace activity, encouraged patient to eat nutritious foods such as green
leafy vegetables and lean meat, instructed patient to report any untoward signs and
symptoms observed.
R – Oxygen Saturation increases from 89% to 94%
Tulagan, Allen Vincent C Anod, Nasper
UC-BSN3B-2B UC-CI
Treatment Record
Medication/Treatment Date: 11/09/20 11/10/20 11/11/20

7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7
Shift/Time
Prednisone 60 mg po q8 hr 8/AT
Azithromycin 500 mg po x 1 8/AT
Acetaminophen 650mg po q 4hrs 8/AT
12/AT
Monitoring Sheet
Weight: 57kg
Date/Time BP CR RR TEMP O2SAT URIN STOO Additional Parameters as Ordered
. E L
11/09/20
8:00am 130/70 77 31 37.9 89%
10:00am 120/80 86 25 37.6 90%
3:00 pm 120/70 88 23 37.5 91% 3 0
INTRAVENOUS FLUID (IVF) FORM
MainLine
No. of Type of fluid Volume & Date & Time Printed Name & Date & Time Printed
bottle (include Duration/Regulation Started Signature of Nurse on Consumed/Dis Name &
medications/incorpor Duty continued/Revi Signature
ated sed of Nurse on
Duty
Side Drip
No. of Type of fluid Volume & Date & Time Printed Name & Date & Time Printed
bottle (include Duration/Regulation Started Signature of Nurse on Consumed/Dis Name &
medications/incorpor Duty continued/Revi Signature
ated sed of Nurse on
Duty
KARDEX
Date Ordered Special Endorsement Date Remarks Date Diet
(Ordered Procedures, Monitoring, Referrals.) (Patients Status Upon Receiving)
11/09/20 -VS: Q 2hour x 2, then Q 4 hours and prn (with
pain assessment)
-Notify physician if O2 sat is less than 90% on
current O2 therapy
Date Ordered Medication Treatment Date Medication Treatment (Indicate to

(Indicate to start,on,hold,revise or discontinue) Ordered start,on,hold,revise or discontinue)
11/09/20 Prednisone 60 mg po q8 hr;

Acetaminophen 650mg po q 4 hrs prn for
fever or pain
Date Ordered No. Intravenous Fluid (Main Line) Date No. Intravenous fluid
Ordered (Side Drip)
Date No Blood Transfusion
Ordered
Name: Austin Vien C. Tulagan Hospital No. 18-1505-819

Diagnosis: Age: 16 Sex: Male

CHARTING

Uploaded by

Copyright:

Available Formats

CHARTING

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CHARTING

Uploaded by

Copyright:

Available Formats

CLINICAL HISTORY AND PHYSICAL EXAMINATION

Date:11/10/2020 Informant: Patient

Name of Patient: Austin Vien C. Tulagan Hospital No.18-1505-819

Physicians Order Sheet and Progress Notes

Name of Patient: Austin Vien C. Tulagan Hospital No.18-1505-819

Name of Patient: Austin Vien C. Tulagan Hospital No.18-1505-819

Medication/Treatment Date: 11/09/20 11/10/20 11/11/20

INTRAVENOUS FLUID (IVF) FORM

Name of Patient: Austin Vien C. Tulagan Hospital No.18-1505-819

Date Ordered Medication Treatment Date Medication Treatment (Indicate to

11/09/20 Prednisone 60 mg po q8 hr;

Name: Austin Vien C. Tulagan Hospital No. 18-1505-819

You might also like