History:
Patient presents today with a three-day history of a worsening cough, accompanied by a runny nose and mild fever. The cough is dry and non-productive, located in the chest, and aggravated by lying down. No radiation. Alleviating factors include rest and over-the-counter cough medicine. Associated symptoms include fatigue and a mild headache.
Past Medical History: Unremarkable.
Surgical History: Unremarkable.
Family History: Father with a history of hypertension.
Social History: Non-smoker, drinks alcohol occasionally. Works as a software engineer.
Review of Systems: Otherwise unremarkable.
Examination:
General Appearance: Alert and oriented.
Vital Signs: Temperature 37.8°C, Pulse 88 bpm, Blood Pressure 120/80 mmHg, Respiratory Rate 18 breaths/min, SpO2 98% on room air.
Respiratory: Mildly congested nasal passages. Clear lung sounds bilaterally on auscultation. No wheezes or crackles.
Diagnosis or Impression:
Upper Respiratory Tract Infection (URTI).
Differential diagnoses: Common cold, influenza.
Management Plan:
Advised patient to rest, stay hydrated, and take over-the-counter paracetamol for fever and headache. Recommended symptomatic relief with cough medicine. Advised to monitor symptoms and return if they worsen or if new symptoms develop. No antibiotics prescribed. Provided patient education on hand hygiene and cough etiquette. Follow-up: Advised to return if symptoms do not improve within one week. Scheduled a telephone consultation in one week if symptoms persist.
History:
[Describe the patient's presenting complaint, including the onset, duration, character, location, radiation, aggravating factors, alleviating factors, and associated symptoms. Include relevant past medical history, surgical history, family history, social history, and review of systems that relate to the presenting complaint.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Examination:
[Detail findings from the physical examination relevant to the presenting complaint, including general appearance, vital signs, and specific system examinations such as cardiovascular, respiratory, gastrointestinal, neurological, musculoskeletal, or dermatological as appropriate.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Diagnosis or Impression:
[State the provisional or confirmed diagnosis/diagnoses based on the history and examination findings. Include differential diagnoses considered.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Management Plan:
[Outline the proposed treatment plan, including pharmacological interventions, non-pharmacological interventions, referrals to other specialists, further investigations ordered, patient education provided, and follow-up arrangements.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)