Family Medicine Specialist's Note

*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.