Attempt: KM is a 16 year old female, with a medical hx of reactive airway disease and eczema without medical intervention, who presents with mother. Patient reports SOB x3 days with mild exertion and a worsening non- productive cough (worse at night) that started x3 weeks ago. She denies CP, but reports tightness/heaviness. She reports runny nose and congestion starting x3 weeks ago and has since resolved. On exam, she is hypoxic at 95% room air; respirations are labored and regular, expiratory wheezing throughout lung fields, and substernal retractions are noted. Reports exposure to secondhand smoke from neighbors. Reports exposure to cockroaches. Denies current prescribed or OTC medications. Denies fever or sputum production.
Attempt: K.H. 16-year-old female, chief complaint of cough and shortness of breath. Cough started 3 weeks ago with cold symptoms of rhinorrhea and congestion, which has since resolved. Cough is non- productive of sputum. Patient denies fever, chills, headache, and fatigue. For the past 3 days patient has been increasingly short of breath. Exacerbated by minimal activity, relieved with termination of activity. SOB and cough worse at night. Assessment positive for tachypnea, mild labored breathing, bilateral expiratory wheezes, diaphragmatic excursion 4cm bilaterally, and subcostal retractions. Negative for hyper-resonant lung fields, no lymphadenopathy, and patient is afebrile. PMH of reactive airway and eczema. Environmental exposed to secondhand smoke and cockroaches.