Date: [DATE]
Patient: [PATIENT NAME]
MRN: [MEDICAL RECORD NUMBER]
Attending Physician: [DOCTOR NAME]
Subjective:
Present illness: Briefly summarize the patient’s current respiratory symptoms, including onset, duration, severity, and any progression. Focus on cough (productive or non-productive, sputum color/consistency), chest tightness/discomfort, shortness of breath (at rest or exertion), fever, chills, fatigue, and wheezing.
Past medical history: Briefly mention any relevant past medical history, including smoking history, asthma or other chronic lung diseases, allergies (seasonal, medication), and history of prior bronchitis episodes.
Social history: Briefly mention any pertinent social factors, such as recent travel, exposure to irritants (smoke, dust), occupational exposures, and living situation (second-hand smoke exposure).
Objective:
Vital signs: Record current vital signs, including temperature, heart rate, respiratory rate, oxygen saturation (if indicated by symptoms).
Physical exam:
General: Note appearance of illness, respiratory effort (use of accessory muscles, rapid breathing).
HEENT (Head, Ears, Eyes, Nose, Throat): Look for signs of upper respiratory infection (congestion, sore throat).
Lungs:
Inspect for chest wall symmetry and retractions.
Perform auscultation to assess breath sounds (presence of wheezing, crackles).
Cardiovascular: Briefly assess heart rate and rhythm for any abnormalities.
Assessment:
Summarize the patient’s clinical presentation, incorporating findings from history, physical exam, and vital signs.
State the working diagnosis (e.g., acute bronchitis) with a level of certainty (e.g., highly likely, possible). Consider alternative diagnoses (e.g., asthma exacerbation, pneumonia).
Plan:
Outline the treatment plan, focusing on symptom management and promoting recovery.
Bronchodilators (inhalers) – If wheezing is present, consider a short-acting bronchodilator to ease breathing.
Cough suppressants – May be helpful for nighttime cough to improve sleep (use cautiously and avoid with productive cough).
Expectorants – May help loosen mucus and make coughing more productive (consider for productive cough).
Supportive measures – Encourage increased fluid intake, use of a humidifier, and rest.
Smoking cessation counseling – If applicable, strongly advise smoking cessation to improve lung health and prevent future episodes.
Re-evaluation – Schedule a follow-up appointment to assess symptom improvement and ensure resolution of the infection.
Consider chest X-ray or other investigations if suspicion for pneumonia, complications, or atypical presentation is high.