Dear Dr. Emily Carter,
Lily was seen in follow-up today in the respirology clinic.
**Background/Problem List:**
- 1. Asthma, confirmed by clinical history and pulmonary function testing.
- 2. History of seasonal allergies.
- 3. History of eczema.
**Plan from last clinic visit:**
- 1. Continue with current asthma medications.
- 2. Review inhaler technique at next visit.
- 3. Follow-up in 3 months.
**Current Medications:**
- Fluticasone/Salmeterol 100/50 mcg, 2 puffs twice daily
- Albuterol inhaler as needed
**Interim History:**
- Patient has had no significant changes in symptoms since last visit.
**Asthma control:**
- Daytime symptoms: 0/week
- Nighttime symptoms: 0/week
- Physical activity: normal (not limited)
- Exacerbations: None
- Absence from school: None
- Need for reliever: 0 days/week
**Past medical history:**
- No new updates since last visit.
**Respiratory Review:**
- Past hospitalizations for respiratory symptoms: 1
- Past ED/urgent care visits for respiratory concerns: 2
- Number of oral steroid courses in last 12 months: 0
- Previous pneumonias: 0
- Previous respiratory investigations (PFTs, chest x-rays): PFTs performed 6 months ago.
- History of chronic wet cough (>4 weeks): None
- Foreign body aspiration/choking: None
- Exercise intolerance/dyspnea: None
- Episodes of stridor: None
- Sleep apnea symptoms: None
**Atopic history:**
- History of eczema: Yes
- Environmental allergies/allergic rhino-conjunctivitis: Seasonal allergies
- Food/drug allergies: None
- Previous skin prick testing: Performed 1 year ago.
**Review of Systems:**
- No new findings.
**Physical Exam:**
- Ht: 120 cm Wt: 22 kg
- General: Well-appearing, no distress.
- Respiratory: Clear to auscultation bilaterally, no wheezing.
- CVS: Regular rate and rhythm, no murmurs.
**Investigations:**
- PFTs:
- Date and location: 20 October 2024, local clinic
- Quality of test: Good
- FEV1/FVC Pre: 85%
- FVC Pre: 90%
- FEV1 Pre: 88%
- BD Response: 12%
- No significant changes from previous PFTs.
**Imaging:**
- None recently.
**Impression:**
- Lily is a 6-year-old female who was seen in follow-up today for asthma management. Asthma is well controlled. No increased risk of exacerbations. No asthma-related comorbidities.
**Plan:**
- 1. Continue current medication regimen.
- 2. Review inhaler technique at next visit.
- 3. Follow-up in 6 months.
I reviewed key asthma education today with the family. I provided the family with an updated written asthma action plan and explained when to seek urgent medical attention or call 911.
Dr. Thomas Kelly, MD, Paediatric Respirologist
"Verbal consent was obtained from the patient for the use of an AI-assisted scribe in documentation, with privacy and PHIPA compliance explained."
