Medical Report: Progress Note 1
Patient Name: Emily Carter Date: September 9, 2024 Provider: Dr. Michael Lewis Visit Type: Follow-up Chief Complaint: Follow-up for management of asthma and recent exacerbation. Subjective: Patient reports improvement in asthma symptoms since starting new inhaler. However, occasional wheezing at night persists. Objective: Vital Signs: Blood Pressure: 118/76 mmHg Heart Rate: 80 bpm Respiratory Rate: 16 bpm Temperature: 98.2°F (36.8°C) Respiratory Exam: Breath sounds clear bilaterally, occasional wheezing noted in the right lower lung field. Medication Adherence: Adheres to new inhaler regimen but reports occasional missed doses. Assessment: Asthma symptoms partially controlled with current medication. Persistent nocturnal wheezing may indicate suboptimal control. Plan: Continue current inhaler therapy. Increase the frequency of the use of the inhaled corticosteroid. Educate patient on proper inhaler technique and the importance of regular use. Schedule follow-up appointment in 4 wee...