Clinical note · #44
Consultation
Patient: Rachel Thompson
Age: 34
Place of Service: Office – Outpatient
Patient Status: Established Patient
Insurance: Commercial PPO
Primary Provider: Dr. M. Nguyen (Pulmonology)
Reason for Visit: Follow-up evaluation for worsening asthma symptoms.
Chief Complaint: Increased wheezing and shortness of breath.
History of Present Illness (HPI):
The patient is a 34-year-old female with a known history of asthma presenting for follow-up due to worsening respiratory symptoms over the past five days. She reports increased wheezing, chest tightness, and shortness of breath requiring more frequent use of her rescue inhaler.
She denies fever, productive cough, chest pain, syncope, or recent emergency department visits. She reports adherence to her maintenance inhaler but notes recent exposure to seasonal allergens.
Review of Systems (ROS):
- Respiratory: Wheezing, shortness of breath
- Cardiovascular: Denies chest pain
- Constitutional: Denies fever or chills
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: Moderate persistent asthma, allergic rhinitis
- PSH: None
- FH: Mother with asthma
- SH: Non-smoker; no occupational exposures
Physical Examination:
- General: Mild respiratory distress
- Respiratory: Diffuse expiratory wheezes bilaterally
- Cardiovascular: Regular rate and rhythm
- Oxygen saturation: 95% on room air
Assessment:
- Asthma with acute exacerbation
Plan:
- Prescribe short course of oral corticosteroids
- Increase inhaled bronchodilator usage temporarily
- Review asthma action plan and trigger avoidance
- Schedule close follow-up if symptoms persist or worsen