Reference no: EM13647781

1. The patient is a 60-year-old white female who presents with a history. Of shortness of breath and cough for two weeks. She has had no fever and the cough has not been productive no one else in the household has been ill. She has tried taking Robitussin and cough does improve for about two hours but then. Her cough returns and she is unable to take any more for two hours.

2. Past medical history is negative she has no chronic illnesses she takes no prescribed medications but does take ibuprofen for stiffness in her back occasionally. Denies previous. Episodes of shortness of breath.

3. Social history is positive. For smoking ½ pack of cigarettes daily for the past 40 years. Is married and has two grown children and four grandchildren one grandchild lives with the patient and her husband.

4. Family history is unremarkable.

5. On physical exam, lungs are clear to percussion and auscultation. Vital signs are stable the patient is afebrile. No lymphadenopathy. Throat is clear mucus membranes are pink and moist.

6. Assessment: Probable bronchitis.

7. Plan: Increase fluids use humidifier Robitussen DM 2 tablespoons q 4h for cough. Return to the office. If no improvement within the next two weeks encouraged to quit. Smoking as this is likely contributing to the cough.