Asthma

Patient Name: Sarah Johnson

Date of Birth: 05/10/1990

Gender: Female

MRN #: 987654321

Date of Service: 04/07/2024

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Chief Complaint

• Asthma exacerbation
• Allergic rhinitis symptoms

History of Present Illness

Ms. Johnson is a 34-year-old female presenting with complaints of worsening asthma symptoms and allergic rhinitis. She reports increased shortness of breath, wheezing, and chest tightness for the past three days. She also complains of a runny nose, sneezing, and itchy eyes. She denies any fever, chills, or cough.

Past Medical History

• Asthma diagnosed at age 10
• Allergic rhinitis diagnosed at age 15
• No history of hospitalizations or surgeries

Medications

• Albuterol inhaler as needed for asthma symptoms
• Fluticasone nasal spray daily for allergic rhinitis
• Montelukast daily for asthma and allergic rhinitis

Allergies

• No known drug allergies

Social History

• Non-smoker
• Works as a teacher
• Lives with two cats but denies pet allergies

Family History

• Mother has a history of asthma
• Father has a history of seasonal allergies

Review of Systems

• Negative for fevers, chills, cough, or sputum production
• Positive for wheezing, shortness of breath, nasal congestion, sneezing, and itchy eyes

Physical Examination

• General: Alert and oriented, no acute distress
• Respiratory: Increased work of breathing, bilateral expiratory wheezing
• ENT: Nasal mucosa pale and swollen, clear rhinorrhea
• Cardiovascular: Regular rate and rhythm, no murmurs or gallops
• Chest: Diminished breath sounds bilaterally, no crackles or rhonchi

Assessment and Plan

1. Acute exacerbation of asthma: CXR was interpreted by me, CXR shows Small patchy infiltrates in the right middle and left lower lung zones. Bilateral involvement, affecting both upper and lower lung fields. Start oral prednisone 40 mg daily for 5 days, increase frequency of albuterol inhaler to every 4-6 hours as needed for symptoms, continue current maintenance asthma medications.
2. Allergic rhinitis exacerbation: Continue fluticasone nasal spray and montelukast as directed.
3. Follow-up in 1 week for reassessment of asthma symptoms and response to treatment.

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Electronically signed by [Provider's Name], MD. Date: 04/07/2024. Time: 11:30.