Asthma

Introduction

Dear Dr. [Referring Doctor's Last Name], I had the pleasure of seeing [Patient First Name], a [Patient Age]-year-old [Patient Gender] at the allergy clinic. [Patient First Name] was referred for an allergy assessment in the setting of possible asthma.

History of Presenting Illness

[Provide a detailed narrative of the patient's asthma management and history. Include the age of onset, specific symptoms such as wheeze, cough, shortness of breath, and chest tightness. List known triggers including viral infections, exercise, animal dander, pollen, dust, temperature changes, and chemical smells. Mention any diagnostic tests performed, such as spirometry, and note if the patient has taken oral steroids or been admitted to the ED or ICU for asthma management. Describe current management strategies, including the frequency of Ventolin use per week and the level of relief it provides. Note the presence or absence of daytime and nighttime symptoms, and any impact on work or school attendance due to asthma symptoms.]

Allergy Review

[insert the following text: The patient has no prior history of seasonal allergies, eczema, medication allergies, venom allergies, or IgE-mediated food allergies]

Past Medical History

[List the patient's past medical history and number them.] For example: 1. [Condition 1] 2. [Condition 2] ...

Medications

[List the patient's current medications and number them.] For example: 1. [Medication 1] [Dosage and Frequency] 2. [Medication 2] [Dosage and Frequency] ...

Medication Allergies

[List any medication allergies or state 'NKDA' if none.]

Social History

[Provide details about the patient's social history, including smoking, alcohol use, occupation, and any relevant lifestyle factors. Provide details about extended health benefits.] For example: [Patient First Name] does not smoke or drink alcohol. [He/She/They] works as a [Occupation].

Environmental History

[Describe the patient's living environment, including details about the home, heating, presence of pets, frequency of bedding washing and any other relevant environmental factors.] [Patient First Name] lives in a [description of home]. There is [description of heating and any environmental factors].

Family History

[Provide details about the patient's family history, especially any relevant medical conditions such as allergies or asthma.]

Physical Exam

BP: [insert BP], HR: [Insert HR] BPM [Insert the following text without editing it: [insert patient's name] appears well. Rhinoscopy revealed mild bilateral nasal inflammation with turbinate hypertrophy. No nasal polyposis. Cardiac exam revealed a normal S1 and S2. Chest examination is clear with no wheezes or crackles. Skin examination did not reveal active eczema patches or urticaria lesions. The rest of the examination is unremarkable.

Skin Test Results

[Insert the following text: Environmental Allergens: Positive skin test to dust mites, cat, dog, tree pollens, grass pollen, molds and weeds. Negative skin testing to dust mites, cat, dog, tree pollens, grass pollen, molds and weeds. Both histamine and saline control are appropriate.]

Impression

[Provide a concise clinical impression based on the assessment.] For example: 1. [Diagnosis]

Impression

[Provide a concise clinical impression based on the assessment.] For example: 1. [Diagnosis]

Plan

[Outline the management plan, including any treatments, medications, investigations and lifestyle modifications.] For example: 1. [Treatment or recommendation] 2. [Medication and dosage]

Follow-up

[Specify the follow-up timeline and any specific instructions for future appointments.] For example: Follow-up: [Timeframe]

Closure

I appreciate the opportunity to participate in [Patient First Name]'s care, and I hope my suggestions are helpful. If any questions arise please feel free to contact my office.