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Subjective data: Patient reports difficulty in breathing over the past week. The patient also mentioned feeling fatigued and noticed her lips becoming dry more often.
Data objective: Vital signs indicate tachycardia with a 120 beat/min heartbeat and an increase in respiratory rate to 25 breaths/min. The physical examination shows that the lungs are clear with reduced air entry from the right side. The blood sugar level is 140 mg/dL
Summary of positive findings in history: The patient’s medical history suggests that she has been managing her chronic illnesses relatively well over time as she has been able to keep her blood pressure under control and her blood sugar levels within normal limits despite having diabetes. She also indicated that her symptoms are not aggravated by asthma.