[doctor] hi alan , how are you ?
[patient] hi , good to see you .
[doctor] good to see you as well . are you ready to get started ?
[patient] yes i am .
[doctor] so , alan is a 61-year-old male , here with complaints of shortness of breath .
[doctor] so alan , what's going on ?
[patient] so over the weekend , uh , i took a very long bike ride , about three hours or so and i got back , i was very light headed , i was short of breath and it really surprised me because i pretty much bike ride every morning and it was never an issue before so i'm a little concerned about that .
[doctor] okay , and have you had any other symptoms ? have you had any fever-
[patient] n-
[doctor] . chest pain ?
[patient] no , but i felt very light headed and , uh , i- it was hard to catch my breath afterwards , so maybe i did have a little chest pain but , uh , it , it eventually went away after about an hour .
[doctor] okay , um , and anyone else sick in your , in your family ?
[patient] no .
[doctor] okay , and any cough ?
[patient] um , i had a little bit of a cough with my first cold in the last year and a half , but that went away after about a week or so .
[doctor] okay , all right . um , and any other symptoms ? i know you went through the review of symptoms-
[patient] mm-hmm .
[doctor] . with the nurse but any nausea or vomiting or abdominal pain ?
[patient] n- no .
[doctor] okay . all right . well , i know that i've treated you for migraines in the past . how are you doing with those ?
[patient] that's been under control . i've , uh , taken medication , i've , uh , avoided bright lights and it's so far so good .
[doctor] okay . all right . and i think we had you on imitrex for that . have you-
[patient] yes , i'm still taking that .
[doctor] all right . and then your reflux , how are you doing with that ?
[patient] managing that as well .
[doctor] okay and everything's working out well with the protonix ?
[patient] yes .
[doctor] okay . and then i know you had the cataract surgery about three months ago , your vision is okay ?
[patient] that was about four and a half months ago and it's been actually great ever since .
[doctor] okay , great . all right , well , we're gon na go ahead and do a quick physical exam . i wan na see your vital signs first .
[patient] sure .
[doctor] hey dragon , show me the vital signs .
[doctor] okay , so looking here , everything looks quite good . your oxygenation is perfect , which is wonderful . let me just take a listen .
[doctor] deep breath . another one . good .
[doctor] so , on your physical exam , your neck is nice and supple . i do n't appreciate any jugular venous distension . your heart is in a regular rhythm , i do n't hear any murmur . your lungs do have a slight wheeze , expiratory wheeze , bilaterally . i can hear it every time you breathe and i see trace lower extremity edema in your lower extremities .
[doctor] so what does all that mean ? you know , you , uh , i'm not quite sure yet but we're gon na review some of your results . hey dragon , show me the chest x-ray .
[doctor] so looking here , this is a very normal chest x-ray . um , i do n't see any pulmonary edema , there's no pneumonia , so we're viewing your chest x-ray as , it's a norm- it's normal .
[patient] good .
[doctor] so , let's look at your pulmonary function test .
[doctor] hey dragon , show me your , the pfts . and looking here again , these look quite good , i'm , i'm quite encouraged by that . that's , that's normal pulmonary function tests . hey dragon , show me the labs . and all of your labs here look quite good here as well so , i- i- i'm very pleased . so , right now my impression of you is that you may have had an asthma exacerbation from exercising and with the allergies , so at this point in time i'd like to go ahead and prescribe you some albuterol inhaler .
[patient] mm-hmm .
[doctor] two puffs every four hours as needed for wheezing or for shortness of breath . and , i'd like to go ahead and order a pulmonary referral for you , okay . do you have any questions about that ?
[patient] no questions , thanks .
[doctor] hey dragon , order a pulmonary referral . hey dragon , order albuterol inhaler , two puffs every four hours , as needed for shortness of breath .
[doctor] and then i think from your reflux standpoint , everything seems stable and your migraines , i think that we should just continue on with the imitrex , as needed . does that sound good to you ?
[patient] that sounds fine .
[doctor] i wan na see you in a couple weeks and if you have this shortness of breath again , i want you to call me right away , okay ?
[patient] you got it .
[doctor] all right . good to see you .
[patient] same here .
[doctor] hey dragon , finalize the note .

Medical orders:
description: see you couple weeks
order_type: followup
description: albuterol inhaler two puffs every four hours as needed
order_type: medication
reason: asthma exacerbation