[##]-year-old [male/female] with
history and exam consistent with acute exacerbation of asthma.
Initial consideration in this patient
included exacerbation of asthma, acute bronchitis, pneumonia, influenza, COPD
exacerbation, allergic rhinitis, upper respiratory infections (URI), foreign
body airway obstruction, pulmonary embolism (PE) among others.
Patient presented for [cough/shortness
of breath/wheezing] with a known history of asthma consistent with acute
exacerbation. Patient’s lung sounds were
[notable for expiratory wheezing/noted to be normal]. Patient noted to [have/have no] evidence of
fever or other systemic infectious symptoms.
A chest x-ray [was/was not] obtained [and noted to have no evidence of consolidations
suggestive of pneumonia or other acute abnormality/due to absence of abnormal
lung sounds or other evidence suggestive of pneumonia or other acute
intrathoracic pathology].
[A peak expiratory flow rate (PEFR)
was measured in this patient at presentation, and was noted to be [##]% of
predicted.] Treatment was initiated with
nebulized bronchodilators (albuterol and ipratropium) and [oral/intravenous]
corticostreroids. Patient was noted to
have [significant improvement with this treatment/persistent symptoms which
prompted further treatment with intravenous magnesium sulfate/terbutaline/epinephrine/heliox. The patient was ultimately noted to have
significant respiratory distress requiring initiation of non-invasive positive
pressure ventilation (NIPPV).] The patient
was noted to have a measured peak expiratory flow rate (PEFR) of [##]%
predicted after treatment in the ED [consistent with high likelihood of
successful outpatient management].
We discussed return precautions, specifically for evidence of worsening
or persistent asthma symptoms or difficulty breathing, treatment with [bronchodilators/steroids],
and close follow up with primary care doctor within [2-3 days/1 week] for
further evaluation, and the patient demonstrated understanding and agreement
with this plan. Prior to discharge we ensured
that the patient had refills of all asthma control and rescue medications.
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