• Patient Name: Ann Smith
• Race: Caucasian
• Sex: Female
• DOB: 01/29/1960
• Height: 5'4"
• Weight: 130 lbs

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First office visit with new PCP

Ann is a 45 year old married Caucasian female. She has 3 children (ages 20, 18, 14), all alive and well.

Presenting Complaint

Productive cough and wheezing, increasing in severity and frequency for past 4 months.

Pertinent Past Medical History

Ann began smoking 1 pack per day at age 15, quit at age 25 when diagnosed with exercise-induced asthma. Treated periodically with bronchodilators for exercise-induced wheezing. Last course of therapy completed 6 months ago. No history of drug or alcohol abuse. No known allergies. No flu vaccine.

Family History

• Mother – Age 65. Alive and well. History of hypertension.
• Father – Age 67. Chronic emphysema, uses inhalers.
• Paternal Uncle – Age 69. Recently diagnosed with liver disease.
• Siblings:
  • Brother – Age 43. Alive and well.
  • Sister – Age 40. Asthma.

Occupational History

Has worked as a high school English teacher for 19 years.

Hobbies

Wood-working and furniture restoration.

Current Meds

None

Physical Exam

Wheezing, rhonchi, yellow sputum.

Treatment Plan

Antibiotics (10 days) and rescue inhaler. If no response to treatment, return to clinic in 1 week.