Patient Initials: JK Age: 9 years Sex: Male
Complaints: The patient reported to clinic complaining of a heavy cough, shortness of breath, and audible wheezing. The patient was also having difficulty breathing when sleeping and complains of regular chest congestion. In addition, the patient regularly suffers chest pain. The patient has a previous medical history of asthma and has been using an albuterol nebulizer. The inhaler, however, has not helped alleviate current symptoms. Before reporting to the clinic, the patient was having difficulty completing sentences without stopping to catch a breath. Patient was also finding it hard to use stairs at home.
Family History– Patient was born in the United States and has three sisters and one brother. Patient is the youngest in family and attends primary school. His mother suffered from asthma as a child but it stopped without any medical intervention. His father and siblings have never been diagnosed with asthma. Father is a heavy smoker but he does it outside the house. Occasionally, when he comes near patient after smoking, patient finds it difficult to breath and has to use nebulizer before regaining normalcy.
Health History– Patient was born healthy, weighing 3.7Kgs. Until three years ago, when he was diagnosed with asthma, patient was healthy and rarely fell ill. Patient is active and does not have any physical challenges. Enjoys playing soccer and video games. Patient has healthy appetite and feeds well.
Past Medical History– Patient was first diagnosed with asthma three years ago. At the time, the patient was having difficulty breathing when playing with friends. He was also experiencing regular bouts of bronchitis and other respiratory problems. The asthma diagnosis was confirmed after successful treatment was noted using asthma medication. Patient regularly sees his physician but in two years the prescription has not changed.
Surgical History-Patient got eight sutures on the head three years ago after falling down while playing and sustaining a deep cut. No other surgical procedure has been performed on patient.
Allergies-Patient suffers no known allergies