*Documented via AI scribe. Patient consent taken*
Subjective:
- The patient, a 45-year-old male, presents with persistent cough and shortness of breath for the past two weeks. He reports a history of seasonal allergies and mild asthma.
- Past medical history includes appendectomy at age 30 and hypertension.
- Currently taking Lisinopril 10 mg daily and Albuterol inhaler as needed.
- Social history reveals the patient is a non-smoker, consumes alcohol occasionally, works as an accountant, and lives with his spouse and two children.
- Known allergies include penicillin and pollen.
Review of Systems:
- Constitutional symptoms: Reports fatigue and mild weight loss.
- Eyes: No symptoms reported.
- Ears, Nose, Mouth, Throat: Reports nasal congestion and sore throat.
- Cardiovascular: No chest pain or palpitations.
- Respiratory: Reports persistent cough and shortness of breath, especially at night.
- Gastrointestinal: No symptoms reported.
- Genitourinary: No symptoms reported.
- Musculoskeletal: No symptoms reported.
- Integumentary (Skin): No symptoms reported.
- Neurological: No symptoms reported.
- Psychiatric: Reports mild anxiety due to work stress.
- Endocrine: No symptoms reported.
- Hematologic/Lymphatic: No symptoms reported.
- Allergic/Immunologic: Reports seasonal allergy symptoms.
Objective:
- Vitals: Blood pressure 130/85 mmHg, heart rate 78 bpm, respiratory rate 18 breaths/min, temperature 98.6°F.
- Physical examination reveals clear lung sounds with occasional wheezing.
- Recent chest X-ray shows no acute findings.
Assessment & Plan:
- 1: Asthma exacerbation
- Assessment: Likely asthma exacerbation due to seasonal allergies, supported by subjective reports of cough and wheezing.
- Differential Diagnosis: Considered bronchitis, but less likely due to lack of fever and productive cough.
- Investigations: Plan to perform spirometry to assess lung function.
- Treatment: Increase Albuterol inhaler use to every 4-6 hours as needed, start Fluticasone nasal spray for allergy control.
- Referrals: None at this time.
- Follow-up: Re-evaluate in 2 weeks to assess response to treatment.
- 2: Hypertension
- Assessment: Well-controlled on current medication.
- Differential Diagnosis: None.
- Investigations: Routine blood pressure monitoring.
- Treatment: Continue Lisinopril 10 mg daily.
- Referrals: None.
- Follow-up: Routine follow-up in 3 months.
