HPI

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 36.8°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.