🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-29 06:09:19
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
✅ Summary of Findings
- Cough: Persistent for a week, now with yellowish mucus.
- Fever: Slight fever two days ago (100.5°F).
- Breathlessness: Noticed when climbing stairs.
- No known allergies or history of asthma.
📋 Doctor’s Assessment
- Likely lower lung congestion.
💊 Medications Prescribed
| Medicine | Purpose | Dosage | |----------------------|---------------------------------|--------------------------| | Bronchodilator | Opens airways | As directed | | Antibiotic | To treat possible infection | As directed |
📝 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 heavy exertion
- Wear a mask to prevent spreading infection
📞 Follow-Up
- Return if symptoms worsen
- Call clinic for any urgent queries
Wishing you a speedy recovery!
— Dr. Kalesh