🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-25 10:35:08

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.

Patient: Got it. Thank you, doctor.

Doctor: You're welcome. Feel better soon.

Clinical Notes

🩺 Visit Summary – Dr. Kalesh

Date: [Current Date]
Patient Name: Rajesh
Reason for Visit: Persistent cough worsening over a week, now with yellowish mucus, slight fever (100.5°F), and mild breathlessness

✅ Summary of Findings

  • Cough: Persistent for a week, now with yellowish mucus
  • Fever: Slight fever two days ago (100.5°F)
  • Breathlessness: Experienced when climbing stairs
  • Allergies: None reported
  • Asthma: No history

📋 Doctor’s Assessment

  • Likely bronchial infection or early-stage pneumonia
  • Congestion heard in the lower lungs during examination

💊 Medications Prescribed

| Medicine | Purpose | Dosage |
|----------------------|--------------------------------|--------------------------|
| Bronchodilator | Opens airways | As directed |
| Antibiotic | To treat infection | As prescribed |

📝 Investigations Ordered

  • Chest X-ray – to rule out pneumonia
    (Complete at nearest diagnostic center within 24–48 hrs)

🧘‍♂️ Self-Care Advice

  • Rest as much as possible
  • Avoid exertion
  • Wear a mask

⚠️ When to Seek Immediate Help

  • Fever above 101.5°F
  • Difficulty breathing
  • Chest pain
  • Coughing up blood

📞 Follow-Up

  • Return if symptoms worsen
  • Contact clinic for any urgent queries

Wishing you a speedy recovery!
— Dr. Kalesh

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