[doctor] next patient is emily hernandez . date of birth , march 26 2001 . this is a 20 year old female being seen today for our yearly follow-up for asthma , allergic rhinitis and food allergy . due to insurance changes since our last office appointment in april 2020 , she was switched from symbicort to wixela . she also uses zyrtec in the spring , summer and fall for her seasonal allergy symptoms , which tend to work well . she also has known peanut allergy , she does tolerate almonds and cashews . please put in the asthma section at the very bottom that the act score is 21 . please put under interval history , written consent is obtained today to use dax for documentation .
[doctor] hi emily , how are you ?
[patient] i'm pretty good , how are you ?
[doctor] i'm good , thank you . so gosh , we last talked a little bit over a year ago and it was just a telemedicine visit , but it seems like you've been doing pretty good . i know there was an insurance change . i think you had switched over to wixela , is that right ?
[patient] yep , that's right , and it's what i'm currently using .
[doctor] okay , and that's the 250/50 dose , correct ?
[patient] yes , correct .
[doctor] perfect . so how does that compare ?
[patient] i mean , it's working well . i really have n't had any issues with it and i take it once in the morning and once at night .
[doctor] and that's one puff twice a day ?
[patient] mm-hmm .
[doctor] okay . and have you been having to use your albuterol inhaler at all ?
[patient] rarely , and if i do it's really just before a workout or something out that , if i know i'm really going to be pushing it .
[doctor] so it sounds like it's around strenuous activity .
[patient] yes .
[doctor] okay . so you can do things like go on a walk or going to the grocery store no problem , and just use it for more exertional stuff ?
[patient] yes . like , if i'm gon na go for a run or something like that i'll really just take it before as a preventative .
[doctor] okay .
[patient] and i've been trying to use my daily if i can a little less because i'm trying to go into the military soon .
[doctor] no kidding , that's great .
[patient] yeah , so i have to be able to operate basically at a certain fitness level without an inhaler .
[doctor] really ?
[patient] yeah , and if i can prove that i'm capable of these activities without an inhaler it makes it easier .
[doctor] and so by inhaler do they mean both your daily and rescue inhalers ?
[patient] mm-hmm . so it's like they'll have a fitness test and basically they'll tell me not to take my inhaler that day before the test , and then they'll see how the asthma affects me . and they're looking to see if it's serious enough to hold me back from joining or whatever . so i have been taking it less and less . and really some days i feel like i do n't need it .
[doctor] and that is the wixela that you're not taking . so on average per week , how many days of the week do you use one puff in the morning and one puff at night ?
[patient] probably about three or four .
[doctor] okay , three to four days per week and the other days it's once a day ?
[patient] yes , that's correct .
[doctor] okay .
[patient] and it's either in the morning or at night that i'm taking it .
[doctor] okay , and do you think that's working okay ?
[patient] i do .
[doctor] great . and any urgent care or er visits at all for breathing over the past year ?
[patient] nope .
[doctor] okay , so i'm going to assume no one has put you on prednisone for breathing issues then .
[patient] nope .
[doctor] okay . and now , military wise , what's the time frame of when you'll be completing some of these exertional tests ? like , what are your next steps ?
[patient] so , hopefully i'm going to be enlisted early spring of 2022 . so that gives me about six to seven months to get to a point where i'm able to exert my body where i do n't really need the inhaler . or at least show them that i have it under control .
[doctor] now when you were in the other room you completed a breathing test , correct ?
[patient] correct .
[doctor] okay , great . so now let me ask you about the allergies , 'cause i know typically you'll use the zyrtec in the spring , summer and fall , correct ?
[patient] yeah , i do n't really ... um , or i'm sorry , i use it more during the spring and fall . i do n't really have to use it too much in the summer .
[doctor] do you use it more just as needed in the summer ?
[patient] yeah , that's right .
[doctor] okay . and have you been taking the zyrtec every day recently since you're right in the mix of spring ?
[patient] not every day , but i do take it on days i know i'm going to be outside a lot . um , i do tend to work outside about three days a week so i'll definitely take it on those days .
[doctor] and does it seem to work pretty well still ? are you happy with it ?
[patient] yeah , it does , it works great .
[doctor] wonderful , good to hear . and then i'm assuming you're staying away from the peanuts . uh , last year you had told me it worked with ... uh , you worked with enterprise rent-a-car and one of the cars had a lot of peanuts in it that you were cleaning out and that gave you hives , uh , when you had touched it , is that correct ?
[patient] yep , that's correct .
[doctor] okay . and has there been anything like that since that experience ?
[patient] no , i do n't think so . i definitely became more cautious after that , so i usually wear , uh , wear long sleeves and change my gloves every time now . so i have n't had a reaction , but i imagine that i probably came into contact with cars that had peanuts in them , but they just d- did n't touch my skin .
[doctor] super . and it sounds like you're really smart about it .
[patient] yeah , and the airplanes , they have peanuts . they give everyone too , so .
[doctor] okay . and you have an epipen that k- that you keep with you , correct ?
[patient] yes .
[doctor] okay . and i'm assuming you're going to need refills , um , i can call you in a new set for the year . typically of course , they expire within a year .
[patient] yeah , okay .
[doctor] and i remember , um , sometime previously you've had some testing for tree nuts , but you do have almonds and cashews , correct ? and- and you do okay with them , or do you avoid all tree nuts ?
[patient] i do tend to avoid all of them but i recall eating some almonds at one point , uh , really soon after we discussed i might not be allergic to tree nuts anymore .
[doctor] okay .
[patient] and i remember having them and nothing happened , but i usually just tend to stay away from them , um , really if i can help it .
[doctor] okay . so sometimes when people have a peanut allergy , the nuts in general just are n't very important to them , so it is very common to avoid both . um , so let's do this . i'll have helen come in and i would love to complete a breathing test on you . if your breathing numbers are looking great we can work on getting you , uh , something lower than wixela . if you look at all of our asthma regimens it is a stepwise process , and wixela is a combination of two medications in one . and , well maybe you do n't need both of'em . uh , maybe you just need one of'em . so we can work our way backwards .
[patient] okay .
[doctor] and so the breathing test will help give us some- some more guidance , we will look at the results in just a moment .
[patient] all right , and so this past year i did get into the bad habit of vaping and smoking , but i have been trying to cut that out . so i should be good , and , um , now i only do just a little bit and i am trying to quit . so i am sure that might have an effect .
[doctor] it can . um , so what we can do today is compare your results with prior results , probably before you started smoking or using the vape .
[patient] okay .
[doctor] yeah . and we'll see where you stand at that point .
[patient] all right , that sounds good .
[doctor] well let me go ahead and listen , so hop on up here for me .
[patient] okay .
[doctor] all right so your ears look good , a little bit of wax on both sides . can i see inside your mouth ? big ahh .
[patient] ahh .
[doctor] good . okay let me take a peek in your nose . all right , good . you can put your mask back on .
[patient] okay .
[doctor] and go ahead take a big breath in and out . good , your lungs sound terrific . i'll listen to your heart , breathe quietly . okay very good .
[patient] awesome .
[doctor] so your breathing test is about the same as it was a couple years ago , and actually looks a little bit better . you may not remember but when we last completed the test in 2019 , uh , do you recall if you were feeling lousy at the time ?
[patient] i think it was the smoke . there were so many fires at that point and i remember coming in and looking out the window and all you saw was the orange and the smoke .
[doctor] yes , you're absolutely right , that was a bad year . that was my first fall here and i was really alarmed . well that explains why at that time your numbers were a little bit lower and today they look better . here's what i think , so you'll have kaiser currently , correct ?
[patient] correct .
[doctor] okay . most insurances do limit what we can use .
[patient] yeah i do know that .
[doctor] okay so option one would be to continue using wixela like you're using it now . we would classify it as off-label and you can use it once a day instead of twice a day , which is fine . some people do that because they just need it once a day , so that's an option . option two would be to actually back up to an inhaler that just has one med .
[patient] mm-hmm
[doctor] so the one that kaiser covers is alvesco . the thing about alvesco , though , is that it would be two puffs in the morning and two puffs at night . so it's a bit more work . um , it's not breath activated but we could step down the lowest dose to see how you do . some of the newer guidelines for asthma that were published this year is recommending trying to treat people with inhalers like wixela or alvesco only when you're ill , or say during smoke season . so minimizing their use to those periods of time versus all year . unless you found out that you're getting
[ inaudible 00:09:25 ] sick having issues every month , then that would indicate would pull back too much .
[patient] okay .
[doctor] that we had too much , yeah .
[patient] okay .
[doctor] um , so we could step back and possibly get you to the point where you just use those inhalers , uh , when you're ill or it's smoke season , but at the first step to do any of that would be to try to drop down to just alvesco .
[patient] okay , that actually sounds really good .
[doctor] okay great . so i will call that in for you , it will be the lower dose , 80 mcg , and you'll have to do two puffs twice a day .
[patient] all right
[doctor] okay and that'll be on the box when i call it in . you can put the wixela off to the side , but do n't throw it away just in case the alvesco does n't work well for you .
[patient] okay , got it .
[doctor] and then ideally we would repeat your breathing test in four months to see how you're doing , and then be able to document that you're doing well . sometimes , not always , the military will require documentation on breathing tests .
[patient] okay .
[doctor] is your pharmacy still the same or did you update it with helen ?
[patient] yeah i believe she updated it . it should be kaiser permanente broadway .
[doctor] okay perfect . i'll make sure it's the alvesco and then i'll renew your albuterol and epipen as well .
[patient] awesome , thank you .
[doctor] you're welcome . uh , then the zyrtec , do you pick it up over the counter or do get- do you get it as a prescription ?
[patient] i just get it over the counter .
[doctor] okay got it . and do you have a nebulizer that you would , uh , need refills on ?
[patient] i do n't think i need any refills , i have n't used that in such a long time . i think the last time was when i had bronchitis , or there was few select times when i had to use it when i was kid .
[doctor] okay good . well i think we have our game plan .
[patient] okay awesome .
[doctor] and do the alvesco two puffs twice a day and your albuterol if you need it . the zyrtec 10 milligrams as you need it and continue to stay away from peanuts and tree nuts and i'll refill your epipen .
[patient] okay
[doctor] all right so we've got it .
[patient] great .
[doctor] all right i'll have you take this to the front and i'm gon na say four months re-check for asthma and we'll repeat the spirometer- spirometry at that time .
[patient] okay sounds good .
[doctor] all right well thanks so much and you have a great day .
[patient] you too .
[doctor] and we'll do a follow-up in four months with act and spirometry , sooner if needed . follow-up 25 minutes .

Medical orders:
description: inhaler put the wixela off to the side wixela
order_type: medication
description: four months re-check
order_type: followup
reason: asthma
description: albuterol inhaler
order_type: medication
reason: asthma if you need it
description: epipen
order_type: medication
reason: peanut allergy
description: alvesco two puffs in the morning at night 80 mcg
order_type: medication
reason: asthma