ASTHMA MDT BIOLOGIC PRE REFERRAL DISCUSSION:
History:
Patient presents with a 7-year history of asthma, initially diagnosed at age 14. Asthma is triggered by exercise and seasonal allergies. Previous treatments include inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA), with poor symptom control.
Current Drug History:
* Budesonide/Formoterol 160/4.5 mcg, 2 puffs twice daily
* Montelukast 10mg once daily
Smoking History:
Patient is a non-smoker.
Social History:
Patient is a student. Lives with parents and siblings. No significant social factors impacting asthma management.
Previous Medical History:
No other significant medical history.
Blood Results:
Total IgE: 450 kU/L
Eosinophil Count: 600 cells/µL
Lung Function Tests:
FEV1: 70% predicted
FVC: 80% predicted
FEV1/FVC Ratio: 0.88
FeNO: 55 ppb
BMI: 24
Steroid Courses in the Last 12 Months:
3
ENT and Gastro Symptoms:
Occasional post-nasal drip, treated with over-the-counter antihistamines.
Discussion Status:
First discussion.
ASTHMA MDT BIOLOGIC PRE REFERRAL DISCUSSION:
History:
[describe the patient's history related to asthma, including duration, severity, triggers, and any previous treatments or interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current Drug History:
[list all current medications, including dosages and frequency, specifically for asthma management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Smoking History:
[document the patient's smoking history, including current smoking status, duration, and quantity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
[describe the patient's social history, including occupation, living conditions, and any relevant social factors impacting asthma management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous Medical History:
[document the patient's previous medical history, including any other chronic conditions, surgeries, or hospitalizations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Blood Results:
Total IgE: [total IgE level] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Eosinophil Count: [eosinophil count] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[include any other relevant blood test results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
CT Scan and Chest X-ray Findings:
[describe the findings from the CT scan and chest X-ray, including any abnormalities or relevant observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Lung Function Tests:
FEV1: [FEV1 value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
FVC: [FVC value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
FEV1/FVC Ratio: [FEV1/FVC ratio] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
FeNO: [FeNO value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[include any other relevant parameters of lung function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
BMI: [BMI value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Steroid Courses in the Last 12 Months:
[number of steroid courses used in the last 12 months] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ENT and Gastro Symptoms:
[describe any ENT symptoms, including post-nasal drip, and treatments tried] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe any gastro symptoms, including GORD, and treatments tried] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Discussion Status:
[comment on whether this is the first discussion or a re-discussion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
