Ms. [Name] returns with some shortness of breath with exertion, and purulent bronchitis. She does have a history of asthma. She has not used her inhalers recently. Her past medical history is otherwise unremarkable. She is not 77. Current medications have simply been Flonase.
On exam today she appears somewhat ill. Her blood pressure 142/90. Temp 36.6. O2 sat 96%.
Skin: Nothing suspicious.
HEENT reveals erythema in the throat.
The neck is supple without JVD, or bruits.
The lungs reveal mild end-expiratory wheezes.
Cardiovascular: No murmur.
She also has some purulent rhonchi.
ASSESSMENT
1. Purulent bronchitis with bronchospasm.
2. Tracheobronchitis as well.
PLAN
We will add albuterol 2 puffs t.i.d., and Flovent 1 puff b.i.d.; if
On exam today she appears somewhat ill. Her blood pressure 142/90. Temp 36.6. O2 sat 96%.
Skin: Nothing suspicious.
HEENT reveals erythema in the throat.
The neck is supple without JVD, or bruits.
The lungs reveal mild end-expiratory wheezes.
Cardiovascular: No murmur.
She also has some purulent rhonchi.
ASSESSMENT
1. Purulent bronchitis with bronchospasm.
2. Tracheobronchitis as well.
PLAN
We will add albuterol 2 puffs t.i.d., and Flovent 1 puff b.i.d.; if