Patient Name: John Doe
Date of Birth (DOB): 05/14/1980
Medical Record (MR) #: 123456789
Date of Visit: 01/11/2024
Primary Provider: Dr. Emily Smith, MD, General Practitioner
Chief Complaint (CC):
Persistent cough and shortness of breath for the past two weeks, worsening over the last few days.
HISTORY OF PRESENT ILLNESS (HPI) β DETAILED
Onset: Symptoms began approximately two weeks ago, initially mild but have gradually worsened.
Location: Symptoms are primarily respiratory, with the cough originating from the chest.
Duration: Symptoms have been continuous for two weeks, with increased intensity in the evenings.
Character/Quality: The cough is dry and non-productive, accompanied by a sensation of tightness in the chest.
Severity: Severity rated at 6/10, impacting sleep and daily activities.
Modifying Factors: Symptoms slightly improve with rest and over-the-counter cough syrup, but worsen with physical exertion.
Associated Symptoms: Occasional headaches and mild fatigue, no fever or chills.
Context: Recently returned from a business trip to a high-altitude area. No known exposure to allergens or infections.
Risk Factors: History of mild asthma, non-smoker, no significant family history of respiratory conditions.
Impact on Daily Life: Difficulty performing routine tasks and reduced exercise tolerance.
Additional Notes for Differential Consideration:
Pain-Related Complaints (OLDCARTS Analysis): Not applicable.
Respiratory Symptoms: Persistent dry cough, shortness of breath, no wheezing noted.
Gastrointestinal Symptoms: None reported.
Neurological Symptoms: Occasional mild headaches.
Cardiac Symptoms: No palpitations or chest pain reported.
PRELIMINARY ASSESSMENT & NEXT STEPS
Likely Diagnosis: Viral bronchitis with consideration for asthma exacerbation.
Plan: Order chest X-ray and pulmonary function tests. Prescribe inhaler for symptom relief. Recommend follow-up in two weeks or sooner if symptoms worsen.
Physician Signature:
Dr. Emily Smith, MD
Green Valley Health Clinic
Date: 01/11/2024
Patient Name: [Enter Patient Name]
Date of Birth (DOB): [MM/DD/YYYY]
Medical Record (MR) #: [Enter MR Number]
Date of Visit: [MM/DD/YYYY]
Primary Provider: [Enter Provider Name, Credentials, and Specialty]
Chief Complaint (CC):
[Describe the primary symptom(s) or concern(s) that led the patient to seek medical care. Include duration of symptoms and any specific details related to onset.]
HISTORY OF PRESENT ILLNESS (HPI) β DETAILED
Onset: [Describe when symptoms began, including approximate time frame. Indicate if onset was sudden or gradual, and whether symptoms have worsened or remained stable.]
Location: [Specify the anatomical location of symptoms. If applicable, note whether symptoms are localized or radiate to other areas.]
Duration: [Describe how long the symptoms have been present and whether they are continuous or intermittent. Indicate any worsening over time and variations in symptom intensity throughout the day.]
Character/Quality: [Provide a description of the symptomβs nature, including descriptors such as sharp, dull, burning, tightness, or pressure. For cough, describe productive vs. non-productive and sputum characteristics, if applicable.]
Severity: [Rate the severity of symptoms on a numerical scale if possible (e.g., 1-10). Include impact on daily activities, sleep, and overall function.]
Modifying Factors: [Identify what makes symptoms better or worse, including rest, medications, physical activity, or environmental factors. Note any home remedies attempted and their effectiveness.]
Associated Symptoms: [List any other symptoms that accompany the chief complaint, including systemic, respiratory, cardiovascular, gastrointestinal, neurological, or musculoskeletal symptoms. Specify if symptoms are worsening, improving, or unchanged.]
Context: [Include any relevant preceding events, such as recent illness, travel, exposure to allergens or infections, lifestyle changes, or new medications. Also note if similar symptoms have occurred previously and how they were managed.]
Risk Factors: [Document relevant patient risk factors that could contribute to the current condition, including medical history, smoking, occupational exposure, family history, or any relevant lifestyle factors.]
Impact on Daily Life: [Describe how symptoms affect the patientβs daily activities, mobility, sleep, work, or ability to perform routine tasks.]
Additional Notes for Differential Consideration:
Pain-Related Complaints (OLDCARTS Analysis): [If applicable, describe onset, location, duration, character, aggravating/alleviating factors, radiation, timing, and severity of pain. Note response to medications or position changes.]
Respiratory Symptoms: [Include details on cough, sputum characteristics, shortness of breath, wheezing, and history of exacerbations. Note any changes in baseline respiratory function.]
Gastrointestinal Symptoms: [Describe any nausea, vomiting, diarrhea, constipation, heartburn, or reflux symptoms. Note any associated abdominal pain or bloating.]
Neurological Symptoms: [Document dizziness, headaches, vision changes, weakness, or recent falls.]
Cardiac Symptoms: [Include palpitations, chest pain, syncope, swelling, or any prior history of cardiovascular conditions.]
PRELIMINARY ASSESSMENT & NEXT STEPS
Likely Diagnosis: [Provide an initial diagnostic impression based on history and symptoms. List possible differential diagnoses to consider.]
Plan: [List the next steps for evaluation and treatment, including orders for imaging, laboratory tests, medication adjustments, specialist referrals, and follow-up recommendations.]
Physician Signature:
[Enter Physician Name, Credentials]
[Enter Healthcare Facility Name]
Date: [MM/DD/YYYY]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
