C/c
Patient presents today with a three-day history of a worsening cough, described as dry and hacking, with no associated sputum production. The cough is more frequent at night and is aggravated by lying down. The patient denies any fever, chills, or shortness of breath, but reports mild fatigue and a scratchy throat.
PMHX
The patient has a history of seasonal allergies, managed with over-the-counter antihistamines. No other significant past medical history is reported.
Social history
The patient is a non-smoker and drinks alcohol occasionally, approximately one to two units per week. They are employed as a teacher and live with their partner in a two-bedroom flat.
Medications and allergies
The patient is currently taking loratadine 10mg once daily for allergies. No known drug allergies.
NEWS
Respiration Rate: 16 breaths/min, Oxygen Saturation: 98% on room air, Systolic Blood Pressure: 120/78 mmHg, Pulse Rate: 80 bpm, Level of Consciousness: Alert, Temperature: 37.1°C. NEWS score: 0.
O/E
General appearance: Alert and oriented. Mildly flushed face. Chest auscultation reveals clear lung fields bilaterally with no wheezes or crackles. Throat is mildly erythematous. No lymphadenopathy.
Blood
No blood tests were performed during this visit.
Imaging
No imaging studies were performed during this visit.
Impression
Likely viral upper respiratory tract infection (URTI).
Plan.
Advised to rest, stay hydrated, and take over-the-counter cough suppressants as needed. Reassurance given. Advised to return if symptoms worsen, or if they develop a fever, shortness of breath, or chest pain. Follow-up in one week if symptoms persist. Advised to self-isolate if they test positive for any respiratory viruses.
C/c
[describe the chief complaint(s) including their onset, duration, character, aggravating and relieving factors, and associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph.)
PMHX
[document relevant past medical history, including significant illnesses, hospitalizations, and surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph.)
Social history
[detail the patient's social history, including living situation, occupation, smoking status, alcohol consumption, recreational drug use, and other relevant social determinants of health] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph.)
Medications and allergies
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NEWS
[record the National Early Warning Score (NEWS) components: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness, and temperature, along with the calculated score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph.)
O/E
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Blood
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Imaging
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Impression
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Plan.
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