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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HISTORY OF PRESENT ILLNESS:  In February of this year, he had a significant asthma flare-up and his FEV1 was reduced down to only 0.7 liters or 24% of predicted. He had multiple nebulizer treatments during his visits here for the asthma flare-up. He also had a course of Augmentin and 8 days of prednisone. The patient tells me, after the last visit, it took him about 2 weeks to get back to normal. He is feeling good now. He denies coughing, wheezing, shortness of breath. Since the pollen has been out, he does notice a bit of throat clearing and has used ProAir inhaler about 3 times this past week. He is a bit congested, but it is not too bothersome. He has been able to walk on the treadmill 30 minutes at a time. He did start checking his peak flows at home but is not doing it faithfully. He seems to get up to about 350 at home. The patient is getting the Xolair injections 375 mg every 2 weeks and received an injection today. His IgE had been significantly elevated.

MEDICATIONS:  Include ProAir inhaler as needed, Advair 250/50 mcg 1 puff twice daily, Singulair 10 mg daily, Sporanox, Wellbutrin. He has added Allegra a few times this past week and it has helped his congestion.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION:  General: The patient is a healthy-appearing, well-nourished, well-developed male, in no acute distress. Vital Signs: Height is 66-1/2 inches. Weight is 114 pounds. Blood pressure is 100/62. Tympanic membranes are occluded by cerumen. Nose: Mildly edematous and pale. Throat is clear. Neck is supple without adenopathy. Lungs reveal faint forced expiratory wheezes bilaterally but are otherwise completely clear. Heart: Regular rate and rhythm without murmur.

Asthma control test score today is a perfect 25.

Spirometry today reveals a FEV1 of 1.51 liters or 49% of predicted. FEF25-75% is 29% of predicted. Although I do not have his chart today, with comparison to prior visit notes, it looks like this is about his baseline. The results were interpreted by myself.

IMPRESSION:
1.  Asthma.
2.  Allergic bronchopulmonary aspergillosis with bronchiectasis.
3.  Allergic rhinitis.

RECOMMENDATIONS:
1.  Continue with Advair 250/50 mcg 1 puff twice daily but increase this up to the 500/50 mcg strength for any flares for a period of about 2 weeks. I asked that he increase the dose of Advair at the first sign of a cold for a period of about 2 weeks or if he has any increasing difficulties with the pollen in the spring.
2.  Continue Singulair 10 mg daily.
3.  Add Allegra 180 mg daily or Zyrtec 10 mg daily for any allergy symptoms related to the pollen as needed.
4.  Continue Xolair injections 375 mg every 2 weeks.
5.  ProAir 2 puffs every 4 hours as needed.
6.  The patient is going to monitor peak flows at home and keep a log. He will do this regularly during the pollen season as it sometimes bothers his asthma and at the first sign of any illness.
7.  I discussed with the patient that if he is noticing any decline, he should call us. Hopefully, the peak flow meter will give him an indication of when his asthma is becoming worse if he does not seem to notice the symptoms until it gets quite severe.
8.  Follow up as planned with Dr. John Doe.

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