Subjective:
- Patient presents today with a three-day history of a worsening cough, accompanied by a runny nose and fatigue. She reports feeling generally unwell and has a mild headache.
- Patient has a history of childhood asthma, well-controlled with an inhaler. No previous surgeries.
- Current medications include Salbutamol inhaler as needed. No known herbal supplements.
- Patient is a non-smoker and drinks alcohol occasionally. She works as a teacher.
- No known allergies.
Objective:
- Temperature: 37.8°C, Pulse: 88 bpm, Blood Pressure: 120/78 mmHg, SpO2: 98% on room air.
- Chest auscultation reveals mild wheezing in the left lung. Throat is slightly red.
- No laboratory tests performed at this visit.
Assessment:
- Acute upper respiratory tract infection. Possible exacerbation of asthma.
- Differential diagnoses include: Common cold, influenza.
- ICD-10 codes: J06.9, J45.90.
Plan:
- Continue Salbutamol inhaler as needed. Advised to rest and drink plenty of fluids. Consider over-the-counter pain relief for headache. Review symptoms in one week or sooner if symptoms worsen.
- Provided education on proper inhaler technique and signs of worsening respiratory symptoms.
- No referrals needed at this time.
Subjective:
- [Describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Describe past medical history, previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Mention medications and herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Describe social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Mention allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
- [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Laboratory and diagnostic test results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
- [List of issues or diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
- [Treatment plan, including medications, therapies, and follow-up appointments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Patient education and counseling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Referrals to other healthcare providers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)