🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-12-19 15:27:58
Transcript
Doctor: Hello, it's Dr. Dunnies dictating a practice note for our use with AI today. I'm just seeing John for the first time today. He's had a productive cough. He's been to see his family doctor. We started him on antibiotics and prednisone. But he continues to have increasing cough, phlegm production, and sputum that's discolored. The patient will be increased on his prednisone and inhalers will be increased and an antibiotic added. And I'll see the patient in three weeks.
Clinical Notes
SOAP Note
Subjective:
- Chief Complaint: Productive cough
- History of Present Illness: Patient reports a productive cough with increasing phlegm production and discolored sputum. He has been started on antibiotics and prednisone by his family doctor but continues to experience symptoms.
- Past Medical History: Not provided.
- Medications: Antibiotics, prednisone.
- Allergies: Not reported.
- Social History: Not provided.
Objective:
- Vitals: Not provided.
- Physical Exam: Not provided.
Assessment:
- Persistent Cough: The patient's symptoms suggest a persistent cough possibly due to an infection or other respiratory condition.
Plan:
- Medications: Increase prednisone dosage, increase inhalers, and add an antibiotic.
- Lifestyle Modifications: Not provided.
- Referral: Not provided.
- Follow-up: Schedule follow-up appointment in three weeks to assess response to treatment.