Fit-in eval regarding wheezing, breathing problems. Off IT because of betablocker. She has done well. She feels that since going off IT she has not had
regression of AR symptoms. New symptoms of cough, wheeze, a little bit of
productive phlegm. Wheezing is moderate. Started with an URI 10 days ago,
wheezing about 7 days ago. Has Proventil HFA, using. It does not seem to help
dramatically. Sometime ago used some Asmanex with some success temporarily. Not
on inhalants with any regularity. Denies GERD, denies toxicity, denies CP,
denies cardiac symptoms on ROS 14-point.
PHYSICAL EXAMINATION:
VITAL SIGNS: SO2 on RA 97 percent. P 98.
GENERAL: Coughing episodically.
CHEST: There are some expiratory wheezes auscultated bilaterally mid and lower
fields throughout. Rare rale. Rare coarse breath sound. Adequate air flow.
CV: RR.
HEENT: NCAT. PERRLA. EOMI. TMs clear. NP 1 to 2. No PDNLP.
EXT/NEURO: Nonfocal.
IMPRESSION: Asthmatic respiratory abnormality. Based on age and auscultation,
respiratory tract infection likely. Will have bacterial component, not full
pneumonia. I believe though Zithromax, one Z-PAK, prednisone 30 mg day 1, 20 mg
days 2 through 5, 10 mg day 5. May start Asmanex 2 P per day. Xopenex is given
as well, 1 to 2 p.r.n. basis. Limit no more than q. 4. Discussed possible
current stim. Discussed signs and symptoms warranting followup if needed.
Counseling greater than 50 percent for complexity, 25 min.
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