Chief Complaint:

Shortness of breath, Hives and Fever

History of Present Illness:

Mr. Jackson Wang is a previously healthy 19-year-old gentleman who presents with a four-day
history of shortness of breath, hives and fever. He was unemployed, and the symptoms began
four days prior to admission, while he was doing his morning exercise routine. He was at his
apartment, the day after the symptoms began, where worsening of his dyspnea and hyperthermia
prompted him to go to the emergency room. There, he was diagnosed with pneumonia and
placed on Salbutamol Guaifenesin 10 ml TID, which he has been taking for two days with only
slight improvement. He then went to Buntun, Tuguegarao City, his hometown, and continued to
experience shortness of breath, hives and fever. He presented to an urgent care office in town
today, and was subsequently transferred to the ER due to worsening condition.
The hives are in his left shoulder. The appearance of is swollen, about 7/10 in severity, and
worsens when not intervened with medication. He feels that the hives has improved somewhat
over the past two days. The dyspnea has been severe, and it is difficult for him todo his usual
routines. He states that he feels as though there is a “rattling” in his chest. At baseline, he
experiences no dyspnea on exertion and has no history of COPD or other respiratory problem.
He is not a smoker. He also notes a four-day history of cough, nausea, and subjective fever and
fatigues, with a measured fever of 103 in the hospital in Newville Buntun. He had a bout of
pneumonia in 2018 but has been healthy for the most part and denies any chronic medical
conditions. Currently he is comfortable, with morphine helping with the pain. He has no history
of a clotting disorder, no cardiac history, and denies any chest trauma or aspiration. He has had
no sick contacts.
Past Medical History:
1.Pneomonia

Medications:
Montelukast (Zycast) 10mg tablet, Once a day (6 months medication)
Prednisone (Pred 10) 10mg tablet, every allergic reaction Salbutamol
Guaifenesin (Broncaire expectorant) 10ml TID.

Allergies:
Shrimp, Egg, Eggplant, and Chicken with the manifestation of occurrence of rashes and have
difficulty in swallowing
Ibuprofen (Medicine) with the occurrence of facial swelling and watering of the eye House
Dust that results in hives and have difficulty in breathing
Review of Systems:
Constitutional: Fatigue, cough HEENT:
Series of headache.
CV: No palpitations, edema.
Resp: See HPI
GI: Nausea
GU: No dysuria, increased frequency.
Neuro: No weakness, confusion, numbness, dizziness.
MSK: No weakness, arthralgias, myalgias.
Heme: No easy bruising, easy bleeding.
Skin: Presence of rashes.
Endocrine: No polydipsia, polyuria, heat/cold sensitivity.

Social History:
Mr. Jackson Wang is single, lives in Newville Buntun, and has been at home helping his family
with their needs. He lives with his parents. He has no children. His family is very supportive, and
they get along well. As per HPI, he does not smoke. He does not drink alcohol or use other
drugs. He is physically active, and his favorite type of exercise is Cardiovascular Exercise.

Family History:
Family has history of lung disease.
Mother has a series of migraines Father
has asthma.
Sister has rheumatic heart disease.
Brother has high blood pressure.

Physical Examination:
Vitals: Temp:99.1 F Pulse: 88 Resp. Rate: 24 BP: 114/78 O2 sats: 90% on room air 95%
on 4L oxygen

General: Alert, calm, well-developed male. Height/weight proportionate. No acute distress.

HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular movements
intact. Moist mucous membranes in oropharynx. Some darkened teeth; possible caries. Small,
reddened, raised area on left tonsilar pillar.

Neck: Supple, without lymphadenopathy or thyromegaly. No carotid bruits.

Lymph: No axillary, cervical, supraclavicular, pre-auricular, submental, or occipital

lymphadenopathy,
Cardiovascular: Regular rate and rhythm, with normal S1 and S2. No murmurs, rubs, or
gallops. No JVD. 2+ pulses bilaterally – dorsalis pedis and radial.

Lungs: Diffuse, bilateral crackles throughout lung fields. No wheezes. No accessory muscle use
or cyanosis. Rhonchi from right lung base extending midway up lung field, very loud. No
egophony. No tenderness to palpation.

Abdomen: Normoactive bowel sounds. Soft, flat, non-tender, and non-distended. No

hepatosplenomegaly; liver span approximately 10 cm.

Skin: Warm, dry, well-perfused. Presence of rashes.

Extremities: 2+ pulses in upper and lower extremities. No lower extremity pain or edema; legs
are symmetric in appearance.

Rectal: Deferred.

Neuro: Alert and oriented to person, place, and time. Able to communicate well. Cranial nerves
2-12 grossly intact. 5/5 strength in all extremities bilaterally. Sensation intact in all extremities.
Normal gait. 1+ DTR’s in biceps, triceps, supinator, knee, ankle. No clonus.

Psych: Appropriate affect.