Summary Focused Exam: Asthma Exacerbation
Gabriel Martinez (Care Plan)
, Patient Summary – Gabriel Martinez
Age/Sex: 22-year-old male
Diagnosis: Acute Asthma Exacerbation
Chief Complaint: “I can’t catch my breath; I feel tight in my chest and wheeze.”
History: Known asthma since childhood. Reports exposure to pollen and recent upper
respiratory infection. Uses albuterol PRN. Symptoms began 24 hours ago with progressive
shortness of breath, wheezing, and cough.
1. Focused Assessment / Summary Exam
Vital Signs:
• Temp: 37°C (98.6°F)
• HR: 110 bpm (tachycardia)
• BP: 125/78 mmHg
• RR: 28/min (tachypnea)
• SpO₂: 88% on room air
General Appearance:
• Mild respiratory distress, using accessory muscles
• Speaking in short phrases
Respiratory:
• Wheezing on inspiration and expiration
• Decreased air entry bilaterally
• Prolonged expiratory phase
Cardiac:
• Tachycardic
• Regular rhythm
• No murmurs
Skin / Extremities:
Gabriel Martinez (Care Plan)
, Patient Summary – Gabriel Martinez
Age/Sex: 22-year-old male
Diagnosis: Acute Asthma Exacerbation
Chief Complaint: “I can’t catch my breath; I feel tight in my chest and wheeze.”
History: Known asthma since childhood. Reports exposure to pollen and recent upper
respiratory infection. Uses albuterol PRN. Symptoms began 24 hours ago with progressive
shortness of breath, wheezing, and cough.
1. Focused Assessment / Summary Exam
Vital Signs:
• Temp: 37°C (98.6°F)
• HR: 110 bpm (tachycardia)
• BP: 125/78 mmHg
• RR: 28/min (tachypnea)
• SpO₂: 88% on room air
General Appearance:
• Mild respiratory distress, using accessory muscles
• Speaking in short phrases
Respiratory:
• Wheezing on inspiration and expiration
• Decreased air entry bilaterally
• Prolonged expiratory phase
Cardiac:
• Tachycardic
• Regular rhythm
• No murmurs
Skin / Extremities:
