Doctor: How're you today? 
Patient: Not too bad. I'm hanging in there. My asthma has been acting up. 
Doctor: Oh no. How long has this been going on? 
Patient: For the past three months. I've been using my inhaler every day. I used to use it every now and again. This is definitely new for me. 
Doctor: Are you experiencing any allergies alongside your asthma? 
Patient: Yes, actually. My husband has been hauling a lot more corn this season and it seems to be making my allergies much worse. 
Doctor: Do you take anything for your allergies? 
Patient: Not really. I'll sometimes take Allegra and that seems to help just a tiny bit. I was previously prescribed Flonase, but I can't remember the last time I took it. Oh and I was on Advair, too. 
Doctor: Did the Flonase or Advair help at all? 
Patient: I had to stop Advair because it started to bother my lady parts. 
Doctor: How so? 
Patient: I noticed that it became more itchy as a result. 
Doctor: I'm sorry to hear that.  
Patient: Speaking of this, I wanted to also share that I've been experiencing a lot of P M S symptoms lately. I'm super impatient and moody.  
Doctor: Do you notice these symptoms are still there after you finish your cycle? 
Patient: Um lemme think. The symptoms start about a week before my period and tend to get less intense once I get over the first day of bleeding. 
Doctor: Are your cycles generally regular? 
Patient: For the most part, yes. I feel like they don't last as long as they used to. I'm not sure why. I do, however, notice some spotting after my cycles end. 
Doctor: Do you get any night sweats or hot flashes while you're on your period? 
Patient: No.
Doctor: Have you had any other medical troubles recently? 
Patient: I did have a U T I and some blood in my urine because of it. 
Doctor: Do you remember how many times you noticed blood in your urine? 
Patient: Hm about three times. I was prescribed antibiotics for it. 
Doctor: Have you had any other urinary symptoms since? How about bdominal pain, nausea, vomiting, or anything of the like? 
Patient: Nothing now.  
Doctor: Have you gotten your urine rechecked recently? 
Patient: No, not yet. I really should get it checked out again. 
Doctor: I can write an order for you if you'd like or you can make an appointment with your urologist. Do you have a specific urologist that you see? 
Patient: Yeah, I can call to make the appointment tomorrow. Do I also need to get blood work done?
Doctor: Yes, in fact I'd like to order some blood work while you're here. 
Patient: I had blood work done a few days ago for my life insurance application. I am forty two so thought I should get that going. My Swedish mother always used to nag about how I procrastinate on important things. Anyways, do I still need to get more blood work done? 
Doctor: Do you know what they checked? 
Patient: I think the typical blood work with cholesterol added.  
Doctor: Do you happen to have a copy on hand or could you fax me the resulxts? 
Patient: I can fax them to you once I get them back. 
Doctor: That would be great. Thank you. Let me write down our fax number for you.

Clinical note:
Symptoms: worsening asthma over the past three months, daily use of inhaler, worsened allergies (especially with corn exposure), irritability and mood changes around menstrual cycle, shorter and occasionally spotting after menstrual cycles, previous urinary tract infection with blood in urine (3+ times).
Diagnosis: N/A
History of Patient: N/A
Plan of Action: order blood work, consider rechecking urine, follow up on life insurance blood work results.