a sample of complete history
patient's name: mary swan
chart number: 660518
date of birth:10-5-1993
sex: female
date of admission: 10-12-2000
date of discharge: 10-15-2000
final discharge summary
chief complaint:
coughing, wheezing with difficult respirations.
present illness:
this is the first john hopkins hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to tedral or cough medicine.
the wheezing progressed and the child was taken to john hopkins hospital emergency room where the child was given epinephrine and oxygen. she was sent home. the patient was brought back to the er three hours later was admitted.