Acute Exacerbation of Asthma Discharge Summary Sample



HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with history of mild intermittent asthma, who was in her usual state of health until admission. The child is managed at home with albuterol p.r.n. Mother denied any daily symptoms of asthma. The child did have some complaints of coughing at night. The child was fine until the evening prior to admission when she developed cough, wheezing, and some chest tightness. Despite multiple puffs of albuterol at home, the child was taken to the emergency room due to her increased work of breathing and increased difficulty in breathing.

Multiple treatments were given in the emergency room without much relief, and the child was admitted to pediatric for further treatment and nebulizer therapy. O2 saturations in the emergency room were 93% on room air.

PHYSICAL EXAMINATION: GENERAL: On admission, the child was alert, in mild acute respiratory distress. LUNGS: The child had diffuse mild wheezing bilaterally. There was decreased air entry. There were no rales noted. The remainder of the physical examination was unremarkable.

ASSESSMENT:  A (XX)-year-old female with acute exacerbation of asthma.

HOSPITAL COURSE:  Albuterol and Atrovent nebulizers were given as well as IV Solu-Medrol, Pepcid, and O2 via nasal cannula to maintain stable O2 saturations. By the next day, the child had shown some improvement but still had some decreased breath sounds over the right lung field but was in no respiratory distress at this point. Nebulizers will be continued as well as IV Solu-Medrol, and the child showed clinical improvement.

On the day of discharge, the child was doing much better, was on room air, still had some decreased air entry of the right lung field but improved from the previous examinations. Due to the child’s clinical improvement, the decision was made to discharge the child home on p.o. Orapred and continue nebulizer therapy at home. The child is to follow up with PMD in 24-48 hours.

FINAL DIAGNOSIS:  Asthma, acute exacerbation.