Elizabeth T. OV - HPI and A&P

CC: Persistent cough and shortness of breath HPI: Elizabeth T. is a 45 y/o female who presents with a persistent cough and shortness of breath that began approximately two weeks ago. The symptoms have gradually worsened, particularly at night, and are accompanied by mild chest discomfort. She reports no fever or chills. The patient’s first issue is a persistent cough, which has been ongoing for two weeks. The cough is dry and more pronounced at night, disrupting sleep. Elizabeth has a history of seasonal allergies but denies any recent exposure to allergens. She has been using over-the-counter cough syrup with minimal relief. A chest X-ray has been ordered to rule out any underlying conditions. The second issue is shortness of breath, which occurs primarily during physical exertion. This symptom started around the same time as the cough. Elizabeth has a history of mild asthma, for which she uses an inhaler as needed. She reports that the inhaler provides some relief. Pulmonary function tests have been scheduled to assess her current respiratory status. New concerns: None reported. Assessment/Plan: Elizabeth T. is a 45 y.o. female who presents today for evaluation of persistent cough and shortness of breath. Chronic cough - Chest X-ray ordered - Continue using over-the-counter cough syrup Shortness of breath - Pulmonary function tests scheduled - Use inhaler as needed "We discussed that if symptoms worsen or persist please return to the office for further evaluation or to the ER if needed." Dr. Thomas Smith “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”