Summary Focused Exam: Asthma Exacerbation Gabriel Martinez (Objective Data)

, Summary Focused Exam: Asthma Exacerbation Gabriel Martinez (Objective Data)




Patient Name: Gabriel Martinez
Date of Exam: [Insert Date]
Primary Physician: [Insert Name]
Presenting Complaint: Acute asthma exacerbation



Past Medical History:

• Asthma: [Mild/Moderate/Severe, Age of Diagnosis]
• Previous Exacerbations: [Frequency, Last Episode]
• Allergies: [List if applicable]
• Other Chronic Conditions: [e.g., COPD, GERD, Hypertension]
• Medication History: [Current asthma medications and adherence]

Recent Hospitalizations:

• Date of Last Hospitalization: [Insert Date or None]
• Reason for Admission: [Asthma/Other]
• Interventions Required: [e.g., Intubation, IV Steroids, ICU Admission]

Recent Lab Results:

• CBC: [Normal/Abnormal - Specify]
• Electrolytes: [Normal/Abnormal - Specify]
• ABG (if applicable): [pH, pCO2, pO2, HCO3]
• Chest X-ray Findings (if done): [Normal/Abnormal - Specify]
• Pulmonary Function Tests (if available): [FEV1, FVC, FEV1/FVC Ratio]
• Sputum Culture (if indicated): [Results]



Assessment Findings:

• Vital Signs:
o Temperature: [Insert] °F/°C
o Heart Rate: [Insert] bpm
o Blood Pressure: [Insert] mmHg
o Respiratory Rate: [Insert] breaths/min
o Oxygen Saturation: [Insert] %