DATE OF VISIT: MM/DD/YYYY
SUBJECTIVE: The patient presents today complaining of chest tightness when she is running. She states for the past two to three weeks when she has been running, she runs for about a mile, and shortly after that, she starts getting some tightness in her chest and she is breathing really fast, almost like she is hyperventilating, and she has to stop and it takes two to three minutes for her to feel normal again. She does not have excessive sweating, and for the first mile, she has no symptoms whatsoever.
In addition to the chest tightness, she also feels that her arms are feeling weak, squeezed when she is running. She had much more mild symptoms when she was running inside the gym. Her sister has a history of reactive airway disease. There is no family history of premature coronary artery disease or sudden death.
OBJECTIVE: Blood pressure 108/62. In general, this is a well-appearing, thin, young lady in no acute distress. Lungs are clear throughout. Heart has regular rate and rhythm. No murmurs. Abdomen has normoactive bowel sounds. No bruits. On examination of the extremities, PT pulses 2+ bilaterally. No edema in either lower extremity.
DIAGNOSTIC DATA: EKG reveals sinus rhythm at a rate of 72 beats per minute. No acute ST or Q wave changes noted, within normal limits.
Office spirometry revealed mild obstruction in the small airways with the FEF25-75% 56% predicted. Peak flow was 76% predicted. Remainder of the lung volumes were within normal limits.
ASSESSMENT: Probable exercise-induced asthma.
PLAN:
1. Albuterol metered dose inhaler 2 puffs 15 minutes before exercise.
2. The patient and/or her mom will call in the next two to three days on her progress, and if she is not having any improvement with the albuterol inhaler, then she will be referred to Cardiology for full evaluation.
