SUBJECTIVE: The patient returns today in followup for chronic obstructive pulmonary disease. Over the last month and a half, she has been doing fairly well. She has had no shortness of breath at rest. She continues to have mild dyspnea on exertion going up stairs. She has had a slight nonproductive cough. She has never had hemoptysis. She has had no wheezing. She has had no nocturnal shortness of breath. She did try using Chantix for smoking cessation; however, she had to discontinue it due to nausea. She continues to smoke 10 cigarettes per day.
OBJECTIVE: No acute distress. Blood pressure 126/58, pulse 94, room air O2 saturation 94%. Head and neck exam were benign. Her lungs were clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm, S1 and S2. Extremities: No clubbing, cyanosis or edema.
I personally reviewed her pulmonary function tests from MM/DD/YYYY, which shows a mild obstructive ventilatory defect without significant improvement after bronchodilator.
ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old woman with a significant smoking history, who has mild chronic obstructive pulmonary disease. Currently, she is asymptomatic. We did discuss starting her on Spiriva. She is not interested in starting an inhaler at this point. We again discussed smoking cessation. She is going to consider joining a smoking cessation class and using a nicotine patch. We would like to see her in 6 months in followup.
Sample #2
SUBJECTIVE: The patient returns today in followup for chronic obstructive pulmonary disease. Over the last six months, she has been doing fairly well. She has had a mild upper respiratory tract infection for the last week with a slight nonproductive cough. Overall, she feels that she is improving. She has had no hemoptysis. She has had no chest pain. She denies any nocturnal shortness of breath. She has no shortness of breath at rest but continues to have dyspnea on exertion when she walks very quickly or up an incline.
OBJECTIVE: The patient is well appearing, in no acute distress. Blood pressure 104/66, pulse 84. Room air oxygen saturation 95%. Head and neck exam were benign. Her lungs had diminished breath sounds bilaterally without wheezing. Cardiovascular: Regular rate and rhythm. S1, S2. Extremities: No clubbing, cyanosis, or edema.
We personally reviewed her chest x-ray from MM/DD/YYYY, which showed some hyperinflation, otherwise clear.
ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old woman with a history of severe chronic obstructive pulmonary disease. Overall, she has been doing fairly well. She is going to continue on Advair and Ventolin as needed. We have recommended that she start on a gentle exercise conditioning program. She is going to consider this. We would like to see her in six months for followup.
Sample #3
SUBJECTIVE: The patient returns today in followup for chronic obstructive pulmonary disease and obstructive sleep apnea. Over the last six months, she has been doing very well. She had a mild upper respiratory tract infection one month ago, which has now improved. She has had no coughing or wheezing. She has not required any albuterol. She has had no fevers or chills. She has had no shortness of breath. She continues to have some mild dyspnea on exertion when she walks up an incline. She continues to use CPAP with supplemental oxygen throughout the night without difficulty. She feels rested in the morning when she wakes up.
OBJECTIVE: She is well appearing, in no acute distress. Blood pressure 142/68, pulse 74, room air oxygen saturation 98%. Head and neck exam were benign. No adenopathy. Her lungs were clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm. S1, S2. Extremities: No clubbing, cyanosis, or edema.
ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old woman with a history of moderate chronic obstructive pulmonary disease and obstructive sleep apnea. Currently, her chronic obstructive pulmonary disease is in good control. She will continue on Spiriva and ProAir p.r.n. Her sleep apnea is in good control with nocturnal CPAP and supplemental oxygen. We would like to see her in one year for followup.
Sample #4
SUBJECTIVE: The patient returns today in followup for chronic obstructive pulmonary disease. Over the last week, she has been more symptomatic with a productive cough of yellowish sputum as well as intermittent wheezing. She has had no fevers or chills. She has been using albuterol, either metered dose inhaler or nebulizer, every 4 to 6 hours. She has had some mild sinus congestion and continues on Flonase. She has had no gastroesophageal reflux. She has no shortness of breath at rest but continues to have mild dyspnea on exertion. She is now walking on a daily basis. She has decreased her cigarette smoking to 10 cigarettes per day.
OBJECTIVE: No acute distress. Blood pressure 124/78, pulse 96, temperature 97.5. Room air oxygen saturation 99%. Head and neck exam were benign. Her lungs had a few scattered expiratory wheezes. Cardiovascular: Regular rate and rhythm. S1, S2. Extremities: No clubbing, cyanosis or edema.
We personally reviewed her pulmonary function tests from MM/DD/YYYY, which showed a mild obstructive ventilatory defect, normal lung volumes, and normal pulse oximetry with ambulation.
ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old woman with a history of chronic obstructive pulmonary disease. Once again, we discussed smoking cessation and how important it is. She is going to consider a setting of quit date. She will continue on her current inhalers. We think she is having a mild chronic obstructive pulmonary disease exacerbation due to bronchitis. She is going to complete an azithromycin Z-Pak and a prednisone taper 40 mg off for the next 8 days. We would like to see her in followup in approximately 6 months, however, we asked her to call us sooner if she is not improving.
