Chief Complaint:
- The patient presents with a persistent cough and shortness of breath.
History of Present Illness (HPI):
- The cough began approximately two weeks ago and has progressively worsened. The patient reports that the cough is dry and occurs mostly at night. Shortness of breath is noted during physical exertion.
- The patient denies any fever or chest pain but mentions that the cough is slightly relieved by sitting upright.
- The patient has a history of seasonal allergies but no previous respiratory issues.
Review of Systems (ROS):
- Positive for cough and shortness of breath. Negative for fever, chills, or chest pain.
Physical Examination:
- The patient appears slightly anxious but is in no acute distress.
- Vital signs: Blood pressure 120/80 mmHg, heart rate 78 bpm, respiratory rate 18 breaths per minute, temperature 36.8Β°C.
- HEENT: Nasal mucosa is slightly swollen, no sinus tenderness.
- Cardiovascular: Heart sounds are normal, no murmurs.
- Respiratory: Mild wheezing noted on auscultation, decreased breath sounds in the lower lobes.
- Abdominal: Soft, non-tender, no organomegaly.
- Musculoskeletal: Normal range of motion, no joint swelling.
- Neurological: Alert and oriented, no focal deficits.
Lab Results:
- Complete blood count (CBC) is within normal limits.
Current Medications:
- Loratadine 10 mg daily for allergies.
Assessment:
- The clinical findings suggest a diagnosis of acute bronchitis, likely exacerbated by seasonal allergies.
Plan:
- Prescribe an albuterol inhaler for symptomatic relief of wheezing.
- Advise the patient to increase fluid intake and rest.
- Schedule a follow-up appointment in two weeks to reassess symptoms.
- Consider referral to an allergist if symptoms persist.
Chief Complaint:
- [describe the main reason for the patient's visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History of Present Illness (HPI):
- [describe the onset, duration, and characteristics of the current issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any associated symptoms or factors that alleviate or exacerbate the condition] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [include any relevant past medical history related to the current issue] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Review of Systems (ROS):
- [list any positive or negative findings from the review of systems] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Physical Examination:
- [describe general appearance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe findings from the head, eyes, ears, nose, and throat (HEENT) examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe findings from the cardiovascular examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe findings from the respiratory examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe findings from the abdominal examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe findings from the musculoskeletal examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe findings from the neurological examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Lab Results:
- [list any relevant laboratory results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Current Medications:
- [mention any current medications the patient is taking] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment:
- [provide a summary of the clinical findings and diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [outline the treatment plan, including medications, lifestyle changes, and follow-up appointments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
