🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-25 10:34:53

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

Subjective

  • Patient: Rajesh.

  • Primary Concern: Persistent cough for a week, worsening with yellowish mucus.

  • Symptoms:

    • Started as a dry cough.
    • Developed yellowish mucus.
    • Slight fever two days ago (100.5).
    • Feeling breathless when climbing stairs.

  • Medical History:

    • No known allergies.
    • No history of asthma.

  • Medication History:

    • Over-the-counter cough syrup used with no relief.

Objective

  • Physical Examination:
    • Lung auscultation reveals congestion in the lower lungs.

Assessment

  1. Respiratory Infection:

    • Symptoms of persistent cough, yellowish mucus, fever, and lung congestion suggest a respiratory infection.

  2. Possible Pneumonia:

    • Chest X-ray ordered to rule out pneumonia due to symptoms and lung findings.

Plan

  1. Medications:

    • Prescribe a bronchodilator and an antibiotic for the respiratory infection.

  2. Diagnostic Tests:

    • Order a chest X-ray to investigate for pneumonia.

  3. Work and Activity:

    • Patient advised to go to work if feeling up to it, but to avoid exertion, wear a mask, and rest as much as possible.

  4. Follow-Up:

    • Instructed to follow up after starting medications and completing the chest X-ray.
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