sample_docs/intake_note_002.txt

PATIENT INTAKE NOTE
Date: 2026-06-01
Clinic: Riverside Family Medicine
Provider: NP Angela Torres

PATIENT INFORMATION:
Name: Maria L. (MRN: 00456)
DOB: 1978-03-14 | Age: 48 | Sex: Female
Insurance: BlueCross PPO

CHIEF COMPLAINT:
"I've had chest tightness and a dry cough for the past two weeks. My inhaler isn't helping much."

HISTORY OF PRESENT ILLNESS:
Ms. L. is a 48-year-old female with known moderate persistent asthma presenting for worsening
respiratory symptoms. She reports using her albuterol rescue inhaler 4–5 times per day over the
past week (baseline 1–2x/week). She denies fever, chills, or productive cough. No recent travel,
sick contacts, or known allergen exposures. Symptoms are worse at night and with exertion.
She mentions increased work-related stress and poor sleep. No ER visits or hospitalizations in
the past 12 months.

PAST MEDICAL HISTORY:
- Moderate persistent asthma (diagnosed 2008)
- Allergic rhinitis
- GERD

MEDICATIONS:
1. Fluticasone/Salmeterol (Advair Diskus) 250/50 mcg — 1 puff inhaled BID
2. Albuterol HFA 90mcg — 2 puffs inhaled PRN (rescue)
3. Montelukast 10mg — 1 tablet by mouth nightly
4. Omeprazole 20mg — 1 capsule by mouth once daily

ALLERGIES:
- Aspirin — bronchospasm
- Sulfonamides — rash

PHYSICAL EXAMINATION:
Vitals: BP 122/78, HR 82 bpm, RR 18/min, SpO2 96% on room air, Temp 36.8°C, Weight 72kg
General: Alert, mild respiratory distress
Respiratory: Mild end-expiratory wheezing bilateral. No accessory muscle use.
Cardiovascular: Regular rate and rhythm, no murmurs.

ASSESSMENT AND PLAN:
1. Asthma exacerbation — Step up therapy. Add oral Prednisone 40mg daily × 5 days.
   Increase ICS/LABA if symptoms do not improve within 48 hours.
2. Consider spirometry at follow-up to reassess control level.
3. Patient educated on trigger avoidance and proper inhaler technique.
4. Follow-up in 2 weeks or sooner if worsening.

FOLLOW-UP APPOINTMENT: June 15, 2026 at 10:00 AM with Dr. Chen.