Date of Encounter: 09/01/2025 Age/Sex: 29-year-old Female Race: Hispanic Insurance: PPO Referral: No referral Reason for Visit: New Consult Chief Complaint: Shortness of breath, wheezing, and cough for 2 days Type of H&P: Focused Type of Decision-Making: Moderate Time with Patient: 35 minutes Consult with Preceptor: 10 minutes Social Problems Addressed: Education/Language, Safety Medications: Albuterol 90 mcg inhaler PRN, Prednisone 40 mg daily x5 days […]



