Sample Consultation Note
Example output from a typical outpatient respiratory consultation. Patient details are de-identified.
Generated in SOAP format (Subjective, Objective, Assessment, Plan).
Subjective
Patient reports a 3-day history of dry cough with mild chest tightness, worse at night. No fever, chills, hemoptysis, or shortness of breath at rest. Oral intake is adequate. No recent travel or known sick contacts.
Objective
Vitals: BP 118/76 mmHg, HR 84 bpm, Temp 98.4 F, SpO2 98% on room air. Chest exam: bilateral air entry present, no wheeze or crackles. Oropharynx mildly erythematous, no exudate.
Assessment
Acute viral upper respiratory tract infection with associated irritative cough. No current red-flag findings suggestive of pneumonia.
Plan
- Hydration, steam inhalation, and voice rest.
- Symptomatic treatment with non-sedating cough suppressant as needed.
- Return if fever, breathlessness, chest pain, or persistent symptoms beyond 7 to 10 days.
- Follow-up in 3 to 5 days if no improvement.