,Patient Information
Name: Jacob Miller
Age: 15 years
Gender: Male
Setting: Emergency Department with Full Imaging and Laboratory
Capabilities
Chief Complaint: Shortness of breath
Date of Visit: July 17, 2025
History of Present Illness (HPI):
Jacob Miller, a 15-year-old Caucasian male, presents to the ED via
ambulance with a 1-day history of acute shortness of breath that began
suddenly while playing basketball at school. He describes the shortness
of breath as a tight feeling in his chest, rated 7/10 in severity,
associated with difficulty catching his breath and audible wheezing.
Symptoms worsened over the past 12 hours, prompting his mother to
call emergency services after he could not complete sentences due to
dyspnea. Jacob reports a nonproductive cough and chest tightness but
denies chest pain, fever, or trauma. He used his albuterol inhaler (2
puffs) three times today with minimal relief, which is unusual as it
typically helps. He denies recent illness, travel, or known exposure to
, allergens beyond seasonal pollen. His mother reports Jacob has a
history of asthma diagnosed at age 8, managed with albuterol as
needed and fluticasone daily, but adherence to fluticasone has been
inconsistent (misses doses 2-3 times/week). Jacob denies syncope,
palpitations, leg swelling, or neurological symptoms. He is anxious
about his breathing difficulty and wants quick relief. EMS administered
oxygen (4 L/min via nasal cannula) en route, improving his oxygen
saturation from 90% to 94%.Past Medical History:
Asthma: Diagnosed at age 8, intermittent exacerbations (1-2 per
year), last ED visit 2 years ago, no hospitalizations.
Seasonal Allergic Rhinitis: Managed with cetirizine PRN.
No Surgical History.
Medications:
Albuterol inhaler (90 mcg/puff), 2 puffs PRN for asthma
symptoms.
Fluticasone propionate inhaler (110 mcg/puff), 1 puff twice
daily (poor adherence).
Cetirizine 10 mg PRN (seasonal allergies, ~1-2 times/week in
spring/fall).
Name: Jacob Miller
Age: 15 years
Gender: Male
Setting: Emergency Department with Full Imaging and Laboratory
Capabilities
Chief Complaint: Shortness of breath
Date of Visit: July 17, 2025
History of Present Illness (HPI):
Jacob Miller, a 15-year-old Caucasian male, presents to the ED via
ambulance with a 1-day history of acute shortness of breath that began
suddenly while playing basketball at school. He describes the shortness
of breath as a tight feeling in his chest, rated 7/10 in severity,
associated with difficulty catching his breath and audible wheezing.
Symptoms worsened over the past 12 hours, prompting his mother to
call emergency services after he could not complete sentences due to
dyspnea. Jacob reports a nonproductive cough and chest tightness but
denies chest pain, fever, or trauma. He used his albuterol inhaler (2
puffs) three times today with minimal relief, which is unusual as it
typically helps. He denies recent illness, travel, or known exposure to
, allergens beyond seasonal pollen. His mother reports Jacob has a
history of asthma diagnosed at age 8, managed with albuterol as
needed and fluticasone daily, but adherence to fluticasone has been
inconsistent (misses doses 2-3 times/week). Jacob denies syncope,
palpitations, leg swelling, or neurological symptoms. He is anxious
about his breathing difficulty and wants quick relief. EMS administered
oxygen (4 L/min via nasal cannula) en route, improving his oxygen
saturation from 90% to 94%.Past Medical History:
Asthma: Diagnosed at age 8, intermittent exacerbations (1-2 per
year), last ED visit 2 years ago, no hospitalizations.
Seasonal Allergic Rhinitis: Managed with cetirizine PRN.
No Surgical History.
Medications:
Albuterol inhaler (90 mcg/puff), 2 puffs PRN for asthma
symptoms.
Fluticasone propionate inhaler (110 mcg/puff), 1 puff twice
daily (poor adherence).
Cetirizine 10 mg PRN (seasonal allergies, ~1-2 times/week in
spring/fall).
