🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-12-19 14:42:02

Transcript

Doctor: Mrs. Souser has been ill over the last 10 days. She had an URI, she has low-grade fever, and she has had some chills and sweats. She has nasal complaints. Her asthma has been markedly more pronounced. She has persistent, troublesome cough throughout the day. With large amounts of white sputum production. She has some chest heaviness. She has wheezing throughout her day. She has dyspnea with any activity. She has no nocturnal respiratory complaints. The patient stopped smoking two weeks ago. She had smoked since the age of 16, often smoking 15 to 20 cigarettes daily. The patient had an exacerbation of her asthma in early November, 2025, treated with prednisone. On examination today, the patient's blood pressure is 127 over 73. Her pulse rate is 87. Her respiratory rate is 20. Her O2 sat on room air is 90%. She has no clubbing or cyanosis of the fingernails. Breath sound intensity is moderately diminished throughout both lungs. Some crackles are noted at both lung bases, and modest numbers of wheezes are noted throughout both lungs. She has normal heart sounds and no heart murmurs.

Clinical Notes

SOAP Note

Subjective:

  • Chief Complaint: Upper respiratory infection with exacerbated asthma symptoms.
  • History of Present Illness: Mrs. Souser has been ill over the last 10 days with a low-grade fever, chills, sweats, nasal complaints, and a persistent, troublesome cough with large amounts of white sputum production. She reports chest heaviness, wheezing throughout the day, and dyspnea with any activity. She has no nocturnal respiratory complaints. Her asthma has been markedly more pronounced. She stopped smoking two weeks ago after having smoked since the age of 16, often 15 to 20 cigarettes daily. She had an exacerbation of her asthma in early November 2025, treated with prednisone.
  • Past Medical History: Asthma.
  • Medications: Prednisone (for recent asthma exacerbation).
  • Allergies: None reported.
  • Social History: Former smoker, quit two weeks ago.

Objective:

  • Vitals: Blood pressure 127/73 mmHg, pulse rate 87 bpm, respiratory rate 20 breaths/min, O2 saturation 90% on room air.
  • Physical Exam:
  • General Examination: No clubbing or cyanosis of the fingernails.
  • Respiratory: Breath sound intensity moderately diminished throughout both lungs, crackles at both lung bases, modest wheezes throughout both lungs.
  • Cardiovascular: Normal heart sounds, no heart murmurs.

Assessment:

  • Exacerbation of Asthma: Likely triggered by an upper respiratory infection, as evidenced by increased symptoms and recent history.

Plan:

  • Medications: Continue prednisone for asthma exacerbation.
  • Lifestyle Modifications: Encourage continued smoking cessation.
  • Follow-up: Schedule follow-up appointment to monitor asthma control and response to treatment.
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