CHIEF

COMPLAINT
chest tightness
difficulty of breathing

HISTORY OF PRESENT
ILLNESS
Two days ago, patient awaken out of sleep
due to difficulty of breathing at 12 midnight
not relieved when nebulized with salbutamol
consistent pain with a scale of 8/10
radiating from chest to scapular area and
lower back, and head especially when
coughing,
aggravated when talking for a long period of
time and relieved when sitting

HISTORY OF PRESENT
ILLNESS
She was admitted after an hour and
was nebulized every 15 minutes.
At 10 am patient was transferred to
another hospital and was given
hydrocortisone which relieved her
condition.
At the 2nd day of admission, patient
experienced coughing and gasping
relieved by nebulizer and oxygen.

PAST MEDICAL HISTORY

Childhood illness:
Had history of chickenpox and measles
7 y/o had history of bacteremia
11 y/o diagnosed with primary complex
3 drug regimen for 6 months
The px took the medication for 2 months

14 y/o 1st experienced chestpain and difficulty of

breathing
Admitted to RLMM
Dx : acute pneumonia / acute bronchitis

 Last month (Oct) px was subjected to 7

days medication (Amoxiclav)
No history of surgery
No known drug allergies