Patient Presents With:
- Main issue(s): Patient presents today with a cough and shortness of breath.
- Other issues addressed: Review of medication, blood pressure check.
---
History [Issues - if identified as an issue addressed, include it as its own issue with its own history]:
1. Cough
- The patient reports a dry cough that started approximately one week ago. It has been worsening, especially at night. The patient denies any fever or chills. The cough is described as non-productive.
- Associated symptoms include mild chest tightness.
- Denies any history of asthma or allergies.
2. Shortness of Breath
- The patient reports shortness of breath that started two days ago, which is worse with exertion.
- Associated symptoms include mild wheezing.
- Denies any chest pain.
- The patient is a 65-year-old male.
- The patient's main concerns are the cough and shortness of breath, which have been progressively worsening over the past week.
- The cough is dry and non-productive, and the shortness of breath is worse with exertion. The onset of the cough was approximately one week ago, and the shortness of breath started two days ago.
- The cough is aggravated by lying down. The patient has tried over-the-counter cough medicine with no relief.
- The symptoms have worsened over the past week.
- No previous similar episodes.
- The symptoms are impacting the patient's ability to sleep.
- Other focal symptoms include mild chest tightness.
---
Systems Review:
- CNS: Denies headache.
- ENT: Denies sore throat.
- CVS: Denies chest pain.
- Resp: Positive for cough and shortness of breath.
- GIT: Denies nausea or vomiting.
- Urinary: Denies any urinary symptoms.
- Bowels: Denies any bowel symptoms.
- MSK: Denies any musculoskeletal symptoms.
- Mental Health: Denies any mental health symptoms.
- Rheumatology/inflammatory: Denies any inflammatory symptoms.
- Endocrine: Denies any endocrine symptoms.
- Circulatory: Denies any circulatory symptoms.
---
PMHx: Hypertension.
Medications: Lisinopril 10mg daily.
Allergies: NKDA.
---
Examination:
- Obs: BP 140/80, HR 80, RR 18, Temp 37.0 C, SpO2 98% on room air.
- Resp: Mild wheezing on auscultation.
---
Investigations: Chest X-ray ordered.
---
Assessment & Plan:
[1. Cough]
- Assessment: Acute bronchitis.
- Differential diagnoses: Pneumonia, asthma exacerbation.
- Investigations: Chest X-ray.
- Treatment: Prescribed Salbutamol inhaler, advised to rest and drink plenty of fluids.
- Safety netting: Advised to return if symptoms worsen, or if they develop a fever or chest pain.
[2. Shortness of Breath]
- Assessment: Possible early signs of COPD exacerbation.
- Differential diagnoses: Asthma, pneumonia.
- Investigations: Chest X-ray.
- Treatment: Prescribed Salbutamol inhaler, advised to rest and drink plenty of fluids.
- Safety netting: Advised to return if symptoms worsen, or if they develop a fever or chest pain.
---
"The patient of this consult has consented to use of an artificial intelligence scribe for assistance with this consult, and agrees to recording of the consult for scribe purposes. I, the clinician who has signed this note, have reviewed it and edited it as required."
