Urgent care with severe shortness of breath

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Date/Time Healthcare Provider Notes 10/15/20XX 1400 The client presents to urgent care with severe shortness of breath. The client has a history of adult-onset asthma 5 years ago after acquiring a novel virus. The client states with much difficulty because of the shortness of breath (SOB), "I was raking leaves at my mother's home this morning without wearing a mask. I know better because I am allergic to mold." Family confirms that the SOB started not long after raking the leaves. The client utilized quick-relief inhaler immediately but received no relief. The client also states that when using the peak flow meter, the result was in the red zone and the family knew to bring the client in for medical care. For each assessment finding in the left column, click to specify if the finding indicates the client's condition has improved, declined, or shows no clinically significant change. Each finding will match one condition. Improved Declined No Clinically Significant Change Pain 9/10 on Numeric Scale P 110 sinus tachycardia BP 138/94 RR 32 Breath sounds wheezing all lobes.

Reference no: EM133697091

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