🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-08-10 18:53:44

Transcript

Doctor: Good morning, come on in. What brings you in today?
Patient: Hi doctor. I have had this nagging cough for about two weeks now, and lately I have been getting short of breath, climbing stairs.
Doctor: Okay two weeks of cough with some exertional shortness of breath, any fever chills or night sweats?
Patient: No fever that I have noticed, but I have been more tired than usual.
Doctor: Any chest pain or coughing up blood or discolored sputum?
Patient: No blood. Sometimes there is a little yellowish mucus, in the morning.
Doctor: Do you smoke or have you been around anyone who has been sick recently?
Patient: I quit smoking about five years ago, but my coworker had a bad cold last month.
Doctor: Got it, let's listen to your lungs, take a deep breath for me, again. Okay I am hearing some mild wheezing in the lower right lobe. I would like to start you on a five day course of azithromycin, 250mg, and an albuterol inhaler for the wheezing. Let's also get a chest x-ray to rule out pneumonia.
Patient: Okay that sounds good.
Doctor: I want to see you back in one week to check how you are responding sooner if the shortness of breath gets worse or you develop a fever. Any questions for me?
Patient: No I think that covers it. Thank you.
Doctor: Great the front desk will get your x-ray order and follow up scheduled. Take care.

Clinical Notes

SOAP Clinical Note

Subjective

The patient presents with a nagging cough lasting for about two weeks and recent onset of exertional shortness of breath, particularly when climbing stairs. The patient denies fever, chills, or night sweats but reports increased fatigue. There is no chest pain or hemoptysis, but the patient notes occasional yellowish mucus in the morning. The patient quit smoking five years ago and was recently exposed to a coworker with a bad cold.

Objective

On examination, mild wheezing is noted in the lower right lobe upon auscultation.

Assessment

The patient is experiencing a persistent cough with exertional shortness of breath and mild wheezing, potentially due to a respiratory infection. Differential diagnosis includes bronchitis or early pneumonia, considering the recent exposure to a sick coworker and the presence of yellowish sputum.

Plan

  1. Prescribe azithromycin 250mg for five days.
  2. Prescribe an albuterol inhaler for wheezing.
  3. Order a chest x-ray to rule out pneumonia.
  4. Schedule a follow-up appointment in one week to assess response to treatment, or sooner if symptoms worsen or fever develops.
  5. Advise the patient to monitor symptoms and seek immediate care if shortness of breath worsens or if fever develops.
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