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Medwriter AI Session
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Live TranscriptionSession: 05:32
Dr: Hi Mr. Smith, what brings you in today?
Patient: I've had this persistent cough for about two weeks now. It's mostly dry, but sometimes I cough up a little phlegm.
Dr: Any fever, chills, or shortness of breath associated with it?
Patient: No fever, but I do feel a bit tired and occasionally get winded going upstairs.
Dr: Okay, let's take a listen to your lungs.
AI-Generated Note
Processing
🗣️SUBJECTIVE:
- Patient is a 45 y/o male presenting with a 2-week history of persistent cough.
- Describes cough as mostly dry, occasional clear phlegm. Denies fever or chills.
- Reports fatigue and mild dyspnea on exertion (climbing stairs).
🩺OBJECTIVE:
- Vitals: Temp 98.6F, BP 125/80 mmHg, HR 75 bpm, RR 18, O2 Sat 97% RA.
- Lungs: Clear to auscultation bilaterally, no wheezes or crackles.
- Heart: RRR, no murmurs.
📋ASSESSMENT:
- Acute Bronchitis (J20.9): Likely diagnosis given symptoms and duration.
- Rule out pneumonia, though less likely given absence of fever and clear lung sounds.
📝PLAN:
- Recommend supportive care: hydration, rest, OTC cough suppressant (e.g., dextromethorphan) PRN.
- Advise patient to return if symptoms worsen, fever develops, or cough persists beyond 3-4 weeks.
- Consider chest X-ray if no improvement in 1 week or symptoms worsen.
- Follow-up PRN.
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