Allergy & Immunology Follow up

John Doe is a 45-year-old male seen today, 1 November 2024, for follow up of chronic allergic rhinitis. Background History: John has a long-standing history of allergic rhinitis, which has been managed with antihistamines and nasal corticosteroids. He also has a history of mild asthma, which is well-controlled with inhalers. Interval History: Since I last saw John, he reports experiencing increased nasal congestion and sneezing, particularly in the mornings. He has also noticed occasional wheezing during physical exertion. His asthma symptoms have been stable, and he has not required any emergency interventions. Physical Exam: Nasal mucosa is pale and swollen. Chest exam reveals clear lung fields with no wheezing. Dermatological exam shows no rashes or lesions. Skin Prick Testing Positive reactions to dust mites and grass pollen. Spirometry: (% Predicted) FEV1: 85% predicted, FVC: 90% predicted Impression/Plan: John Doe is a 45-year-old male we are following for chronic allergic rhinitis and mild asthma. We will continue with his current antihistamine and nasal corticosteroid regimen. I recommend starting a leukotriene receptor antagonist to help with his morning symptoms. Follow up in 3 months to reassess symptoms and spirometry results. This note was generated with the assistance of an AI scribe. Consent obtained before initiation of session.