ASTHMA MDT BIOLOGIC PRE REFERRAL DISCUSSION:
History:
Patient is a 17-year-old male with a 5-year history of asthma. Asthma is triggered by exercise and seasonal allergies. Previous treatments include inhaled corticosteroids and LABAs, with poor symptom control.
Current Drug History:
- Salbutamol inhaler 100mcg, 2 puffs as needed
- Fluticasone propionate/salmeterol 125/25mcg, 2 puffs twice daily
Smoking History:
Patient is a non-smoker.
Social History:
Patient is a student, lives with parents, and has no known social factors impacting asthma management.
Previous Medical History:
No significant previous medical history.
Blood Results:
"Total IgE: 120 kU/L"
"Eosinophil Count: 0.6 x10^9/L"
CT Scan and Chest X-ray Findings:
Chest X-ray shows no acute abnormalities. CT scan not performed.
Lung Function Tests:
"FEV1: 75% predicted"
"FVC: 80% predicted"
"FEV1/FVC Ratio: 0.8"
"FeNO: 45 ppb"
"BMI: 22"
Steroid Courses in the Last 12 Months:
Patient has had 3 courses of oral steroids in the last 12 months.
ENT and Gastro Symptoms:
Occasional post-nasal drip, treated with over-the-counter antihistamines.
No gastro symptoms.
Discussion Status:
This is the 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 transcript, context or clinical note, else omit section entirely.)
Current Drug History:
[list all current medications, including dosages and frequency, specifically for asthma management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Smoking History:
[document the patient's smoking history, including current smoking status, duration, and quantity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
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 transcript, context or clinical note, else omit section entirely.)
Previous Medical History:
[document the patient's previous medical history, including any other chronic conditions, surgeries, or hospitalizations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Blood Results:
"Total IgE: [total IgE level] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)"
"Eosinophil Count: [eosinophil count] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)"
[include any other relevant blood test results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
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 transcript, context or clinical note, else omit section entirely.)
Lung Function Tests:
"FEV1: [FEV1 value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)"
"FVC: [FVC value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)"
"FEV1/FVC Ratio: [FEV1/FVC ratio] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)"
"FeNO: [FeNO value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)"
[include any other relevant parameters of lung function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
"BMI: [BMI value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)"
Steroid Courses in the Last 12 Months:
[number of steroid courses used in the last 12 months] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
ENT and Gastro Symptoms:
[describe any ENT symptoms, including post-nasal drip, and treatments tried] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[describe any gastro symptoms, including GORD, and treatments tried] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Discussion Status:
[comment on whether this is the first discussion or a re-discussion] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) information from the transcript.)
