Medical Record
Patient: Jane Jones
Date of Birth: 8/29/1960

History of Present Illness:
This is an established patient who presents with complaints of a chronic cough, shortness of breath, and a low-grade fever for 2 days. She also states that she has had some chest discomfort and chest congestion. She states she has had a “very bad cold” for the past 2 weeks. She had a history of asthma, and has been using her rescue inhaler more often in recent days.

Past Medical History:
The patient has a history of asthma for the past 40 years which has been controlled by use of medication.
Medications: Flovent inhaler 2x per day, Proventil inhaler 2 puffs every 4 hours as needed.
Physical Examination:
This is a well-nourished female in moderate respiratory distress. Neck is supple without palpable masses. Trachea is midline. Chest with faint wheezing on expiration throughout. Pulse ox is at 94% on room air. Examination of the heart shows no murmurs, gallops, or rubs. Abdomen is soft and non-tender.
Plan: Azithromycin 500mg injection administered. Aerosol treatment Xopenex 0.5mg administered. Pulse ox rechecked after aerosol treatment at 97% on room air with relief of symptoms. Plan home nebulizer every 4–6 hours as needed. Prescription provided for 7-day steroid pack. Prescription provided for Z-Pak antibiotic. Referral provided for Dr. Smith in pulmonology.
Face-to-face time: 25 minutes.

Impression: Acute bronchitis, asthma exacerbation.

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