DATE OF SERVICE: MM/DD/YYYY
PROBLEMS:
1. Pulmonary sarcoidosis, diagnosed four years ago via VATS with lung biopsy. Manifestations thus far have been pulmonary and possibly skin.
2. Asthma, severe persistent, as a child with two prior intubations and a history of cardiac arrest. Pulmonary function testing recently has been within normal limits. He has never had a methacholine inhalation challenge.
3. Recurrent DVTs, on lifelong Coumadin.
4. Allergic and nonallergic rhinitis.
5. Severe atopy with elevated IgA. Skin testing in the past positive for mold, trees, cats, and peanuts.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents today for a followup. We last saw him in February of this year. Since then, he has done fairly well. He denies any increase in dyspnea on exertion. He tries to stay active. He has had no cough.
His chief complaint today is of feeling ” mucousy.” He feels like he has slightly increased rhinorrhea and nasal congestion. There is nothing new in environment. In addition, he denies fever, chills, hemoptysis, chest pain, orthopnea, palpitations or lower extremity edema.
He reports compliance with his Advair. He does not ever feel the need for ProAir. He has had no new problems with his vision. No rash.
CURRENT MEDICATIONS: Reviewed and updated. He is currently on prednisone 2 mg.
SOCIAL HISTORY: He is a nonsmoker.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 122/86, heart rate is 72, respirations 16, and pulse ox is 94% on room air.
GENERAL: He is a well-nourished, well-developed male, in no acute distress.
HEENT: Sclerae anicteric. Mucous membranes dry. Oropharynx clear.
NECK: Supple without lymphadenopathy.
LUNGS: Clear to auscultation bilaterally without audible wheezes or rales. No dullness to percussion. Normal chest excursion. No accessory muscle use.
HEART: Regular rate and rhythm, normal S1, S2. No audible murmur, rub or gallop.
ABDOMEN: Soft and nontender.
EXTREMITIES: Without clubbing, cyanosis or edema.
SKIN: Without visible rash.
NEUROLOGIC: He is awake and alert.
DATA: The patient had spirometry done today, which was reviewed and shows a normal FVC and FEV1. Diffusing capacity is 80% of predicted, down from 86% of predicted.
ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman with a history of pulmonary sarcoidosis, asthma, and allergic rhinitis who presents for followup.
1. Pulmonary sarcoidosis: He continues on subtherapeutic doses of prednisone. He has had no symptoms to suggest worsening pulmonary sarcoidosis. Of note, his diffusing capacity, although still in the normal range, has slowly decreased over the past few years. We will continue to watch this closely. We will have him back in six months for a repeat spirometry and diffusing capacity. In addition, we would like to repeat a CT of the chest, low radiation protocol, at one-year interval from his last. At this point, we will continue to keep him at a subtherapeutic dose of prednisone. This dose is mainly to prevent symptoms of adrenal insufficiency. He follows with Dr. John Doe for this.
2. Asthma: Continue Advair 250/50 one inhalation twice daily. In the future, we may try to step down on this medication to once daily. We have discussed with him how there is some chance that the inhaled corticosteroid portion of the Advair is helping with his pulmonary sarcoidosis as well. In general, he has done very well with his asthma lately.
3. Allergic rhinitis. Continue fluticasone nasal spray and Zyrtec. We have discussed adding a second nasal spray given his slight increase in nasal congestion; however, he would prefer to tolerate this instead of adding another medication. He has been seen by an allergist in the past.
The patient will follow up with us after his CT and repeat pulmonary function testing. He is asked to call if he has trouble prior to that time.
