Allergic Asthma Followup Office Note Transcription Sample

REASON FOR VISIT:  The patient is here for followup of allergic asthma with exercise-induced bronchospasm and allergic rhinitis.

HISTORY OF PRESENT ILLNESS:  The patient has been doing very well taking Flovent 44 mcg inhaler 2 puffs once daily. Xopenex inhaler is used as needed only in relation to exercise. The patient has not had any difficulty with coughing, wheezing or shortness of breath. The patient does not wake from his asthma. He continues to take Claritin RediTabs 10 mg daily and fluticasone 1 spray per nostril daily. This seems to control his allergy symptoms. He has been healthy since his last visit. No ER visits or need for prednisone or antibiotics. The patient received seasonal flu vaccine and is active with cardio and dance.

Skin testing previously had been positive to cat 4+, Alternaria 4+, horse 2+, mite DP 2+, mite DF 1+, and intradermal testing to dog 3+.

They have a pet dog at home, but they keep it out of the bedroom. They have now obtained dust covers for the pillow and mattress. There is wall-to-wall carpeting. They did not have a HEPA filter.

MEDICATIONS:  Claritin 10 mg RediTabs, Flovent 44 mcg inhaler 2 puffs daily, fluticasone nasal spray, Maalox as needed, Xopenex inhaler as needed, Zantac as needed.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION:  The patient is a healthy-appearing, well-nourished, well-developed male, in no acute distress. Height is 46-3/4 inches. Blood pressure is 92/42. Weight is 110 pounds. Tympanic membranes are normal. Nose is 2+ to 3+ pale and edematous with clear discharge. Throat is clear. Neck is supple without adenopathy. Lungs are clear. Heart has regular rate and rhythm without murmur.

Asthma control test scores are 25. This is a passing score.

Spirometry reveals a FEV1 of 2.51 liters or 123% of predicted. FEF25-75% is 28% of predicted. This looks quite good and is similar to prior results. The results were interpreted by me.

IMPRESSION:
1.  Allergic asthma with exercise-induced bronchospasm, well controlled.
2.  Allergic rhinitis.

RECOMMENDATIONS:
1.  Fluticasone 1 spray per nostril daily.
2.  Claritin 10 mg RediTabs daily.
3.  Flovent 44 mcg inhaler 2 puffs once daily, increasing it to twice daily for any flare-ups.
4.  Xopenex 2 puffs every 4 hours as needed and prior to exercise.
5.  Environmental control measures, particularly regarding the dog and dust mites.
6.  Follow up as planned with Dr. John Doe.


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