🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-26 05:32:32

Transcript

Doctor: Good morning. What brings you in today, Rajesh?

Patient: Hi Dr Kalesh, I’ve been having this persistent cough for about a week now, and it’s getting worse.

Doctor: Is it dry or are you coughing up any phlegm?

Patient: It started off dry, but now there’s some yellowish mucus.

Doctor: Do you have any fever, chills, or shortness of breath?

Patient: I had a slight fever two days ago, around 100.5. No chills, but I do feel a bit breathless when climbing stairs.

Doctor: Any known allergies or history of asthma?

Patient: No allergies, and I’ve never had asthma.

Doctor: Have you taken anything for the cough so far?

Patient: Just some over-the-counter cough syrup, but it hasn’t really helped.

Doctor: Alright, let me listen to your lungs.

[Stethoscope sounds – no speech]

Doctor: I hear some congestion in the lower lungs. I’ll prescribe a bronchodilator and an antibiotic. Let’s also get a chest X-ray to rule out pneumonia.

Patient: Okay, sounds good. Should I take rest or can I continue going to work?

Doctor: You can go to work if you're feeling up to it, but avoid exertion and wear a mask. Rest as much as possible. Also, take one Dispirin every day before breakfast.

Patient: Got it. Thank you, doctor.

Doctor: You're welcome. Feel better soon.

Clinical Notes

Subjective

  • Patient: Rajesh, age not provided.

  • Primary Concern: Persistent cough for a week, worsening with yellowish mucus, slight fever (100.5), and breathlessness on exertion.

  • Medical History:

  • No known allergies or history of asthma.

  • Medication History:

  • Over-the-counter cough syrup tried but ineffective.

Objective

  • Physical Examination:

  • Lung auscultation reveals congestion in the lower lungs.

Assessment

  1. Acute Bronchitis: Symptoms of persistent cough with yellowish mucus, low-grade fever, and breathlessness suggestive of acute bronchitis.

  2. Presumed Pneumonia: Chest X-ray ordered to rule out pneumonia due to lung congestion.

Plan

  1. Medications:

  2. Prescribe bronchodilator and antibiotic for acute bronchitis.

  3. Advise taking one Dispirin daily before breakfast.

  4. Investigations:

  5. Order a chest X-ray to evaluate for pneumonia.

  6. Work and Lifestyle Recommendations:

  7. Patient can continue working if feeling well, but should avoid exertion and wear a mask.

  8. Emphasize the importance of rest and adequate hydration.

  9. Follow-Up:

  10. Instruct patient to follow up after investigations and complete the prescribed medications.

  11. Education:

  12. Educate on the importance of completing the antibiotic course and seeking medical attention if symptoms worsen.

  13. Symptom Monitoring:

  14. Advise patient to monitor symptoms and report any new developments promptly.

  15. Symptomatic Relief:

  16. Encourage adequate rest and hydration for symptom relief.

Provider: Dr. Kalesh

Date: SESSION_DATE

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