Patient Name: Agustin Jerde
Date: October 8, 2050
Time: 10:00 AM
MRN: 12345678
Physician: Dr. [Your Name], MD

S: Subjective

• Chief Complaint: "I've been feeling really tired and have a persistent cough."

• History of Present Illness: Mr. Jerde is a 45-year-old male who presents with a 2-week history of fatigue and a dry cough. He reports intermittent fever and night sweats. He denies any chest pain or shortness of breath. The cough worsens at night. He has been taking over-the-counter cough medicine with minimal relief.

• Past Medical History: Hypertension, managed with lisinopril.

• Medications: Lisinopril 10 mg daily, multivitamins.

• Allergies: No known drug allergies.

• Family History: Father with a history of COPD, mother with diabetes.

• Social History: Non-smoker, occasional alcohol use, works as a teacher.

O: Objective

1. Vital Signs:

   • BP: 130/85 mmHg

   • HR: 78 bpm

   • RR: 16 breaths/min

   • Temp: 99.2°F

2. General Appearance: Alert and oriented, appears fatigued.

3. Respiratory Exam:

   • Lungs clear bilaterally on auscultation.

   • No wheezes or crackles were noted.

4. Cardiovascular Exam:

   • Regular rate and rhythm, no murmurs.

5. Abdomen: Soft, non-tender, no organomegaly.

6. Skin: No rashes or lesions.

A: Assessment

Fatigue and dry cough, likely viral etiology. Consideration of possible bronchitis or upper respiratory infection. Differential diagnoses include:

• Viral upper respiratory infection

• Bacterial bronchitis

• Pneumonia (less likely given lung exam findings)

P: Plan

1. Lab Tests:

   • CBC to assess for infection.

   • Chest X-ray if symptoms persist or worsen.

2. Medications:

   • Prescribe a cough suppressant (dextromethorphan) for symptom relief.

   • Advise hydration and rest.

3. Follow-Up:

   • Return in one week or sooner if symptoms worsen (e.g., difficulty breathing, high fever).

4. Patient Education:

   • Educate about the signs of dehydration and when to seek immediate care.

   • Discuss the importance of hand hygiene and avoiding close contact with sick individuals.

Signature:

Dr. [Your Name], MD
General Practitioner

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