DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: The patient was seen in pulmonary consultation for obstructive lung disease.
HISTORY OF PRESENT ILLNESS: The patient has a history of smoking one pack of cigarettes a day up until four months ago. She says she has gone off the wagon a few times since then. She has a history of pneumonia but no history of childhood onset asthma or allergic rhinitis. No history of tuberculosis.
The patient says her breathing was good until four months ago when she had an episode of severe dyspnea and ended up in the hospital. She was in for 48 hours and was treated with antibiotics and Medrol and sent home on a prednisone taper. She has had trouble with her breathing since. It should be noted that she says she has been on the Advair for at least a year and does not know why. She does not hear wheezing but the doctors do. She has not had respiratory infection but has been treated with Levaquin.
Since four months ago, she has been more dyspneic with exertion but cannot quantify it. She had a recurrent flare in early October and was treated with Levaquin and short-course prednisone. She says her cough and dyspnea are better. No sputum production. She is worried about traveling, which she has to do for work, and flaring her asthma.
She does have sinus congestion without any obvious seasonal variation, at least for the last year or two. We have discussed Flonase, what it is, and how she might be getting sinus infections first.
MEDICATIONS:
1. Lorazepam 0.5 mg p.o. q.h.s. p.r.n.
2. Ropinirole 0.25 mg p.o. q.h.s.
3. Ventolin HFA inhaler 2 puffs q.4 h. p.r.n.
4. Advair 1 puff b.i.d.
ALLERGIES: None known.
SOCIAL HISTORY: The patient is married and living at home with her one child being grown and out of the home. The patient’s husband is a nonsmoker.
PULMONARY FAMILY HISTORY: Positive for asthma in her father and brother with her brother’s asthma improving since he quit smoking seven years ago.
REVIEW OF SYSTEMS: Negative for CVA, syncope or severe headaches. No history of hypertension, chest discomfort with exertion, orthopnea, paroxysmal nocturnal dyspnea or pedal edema. No abdominal pain, melena, change in bowel habits or history of acid peptic disease. No diabetes or thyroid abnormality.
PHYSICAL EXAMINATION: The patient is alert and oriented and in no distress at rest. BP 112/72, pulse 90 and regular, respiratory rate 16 and unlabored, weight 116 pounds, height 62 inches, and room air oxygen saturation is 97%. HEENT: Reveals no sinus tenderness and posterior pharynx is clear with no evidence of oral candidiasis. Tympanic membranes are benign. Neck is supple without thyromegaly or adenopathy. Lungs are hyperresonant and hyperinflated to percussion without dullness, and there is no use of accessory muscles. Lungs are clear to auscultation with diminished breath sounds. Wheezing on forced expiration. Heart: Regular rhythm. S1, S2. No murmurs, S3 or jugular venous distention. Abdomen: Normal bowel sounds, soft, nontender. No mass or hepatosplenomegaly. Extremities are without edema. Neurologic: Deep tendon reflexes 2+ bilaterally with no focal deficits.
IMPRESSION:
1. Asthma.
2. Allergic rhinitis.
3. History of smoking one pack of cigarettes a day until quitting four months ago.
4. Strong family history of asthma.
PLAN:
1. Note that chest x-ray was sent by Dr. John Doe, and three weeks ago, it just showed chronic obstructive pulmonary disease with no acute pathology. It was read as showing moderately severe chronic obstructive pulmonary disease.
2. We have discussed the inflammatory nature of asthma and the role of inhaled versus oral steroids.
3. Short-course prednisone to take at the first sign of a flare of her asthma.
4. Increase Advair to 500/50 mcg 1 puff b.i.d. Two samples and prescription.
5. Generic Flonase two sprays bilaterally daily.
6. Continue her nebulizer twice a day as needed.
7. Return for pulmonary followup in two weeks.
