TEMPLATE
Identifying Data: Age, Gender, Occupation, and Marital Status
72 yo, female, retired, and married
Source and Reliability: Patient and medical chart
Subjective
Chief complaint or appropriate health screening visit: The one or more symptoms or
concerns causing the patient to seek care. Need not be the patient’s complete statement
– may be a brief summary of reason patient wanted to be seen for this visit
Patient’s chief complaint of ongoing cough and fatigue that has not gone
away despite prescriptions at initial visit.
HPI: Complete subjective description of problem, including “OLDCARTS” findings or
similar, including location, quality severity, duration, timing, context, modifying factors,
associated signs/symptoms, relieving and aggravating factors, related systems.
Patient states that she has been experiencing an ongoing cough and fatigue
since initial appointment on 01/08/2026 where she was diagnosed with
sinusitis and she received 100 mg doxycycline, a z-pack, and chest x ray.
Patient states she is still coughing, which is worse at night, fatigue, and
feeling hot and cold. patient states she is afebrile. Patient states that she
has had improvement in her condition but continues to experience
significant fatigue. Patient states that her cough is nonproductive. Patient
states that she does not experience wheezing or shortness of breath. Patient
states her asthma symptoms are typically triggered by illness. Patient states
that she is experiencing dizziness when taking deep breaths. She has been
using albuterol nebulizer daily, which provides some relief. patient states
that her symptoms improved while she was on steroids. Patient verbalizes
that she knows that the chest X-ray came back as lungs clear with no acute
findings in the chest. Patient reports that she is frustrated because she
cannot sleep at night due to her coughing which she believes is contributing
to the fatigue.
Medications, including OTC and Herbals Preparation
Abilify: 2 mg tablet, 1 tablet, PRN, orally, Q6H, last dose today, patient states she takes
this medication for depression
Albuterol: 2.5 mg/3 ml, daily, inhalation, last dose today, PRN, Q4H, patient states she
takes this medication for asthma
Tylenol extra strength: 500 mg, 2 tablets, PRN, orally, Q6H, last dose last week, patient
states she takes this medication for mild headaches and pain
, Aspirin: 81 mg, orally, 1 tablet, daily, last does today, patient states she takes this
medication as her blood thinner
Fluticasone: 50 mcq, nasal spray, 2 sprays, nostrils, both, daily, last dose last night,
patient states she uses this for congestion
Past Medical History:
1. Allergies – NKA
2. Childhood Illnesses – asthma
3. Adult Illnesses- anxiety and depression, cough variant asthma, osteoarthritis,
sacroiliac pain
4. Injuries- None
5. Surgeries – partial hysterectomy (7/1/2007), breast reduction (10/01/2005),
rotator cuff repair (right) (02/05/2019)
6. Hospitalizations – none
7. Obstetric/Gynecologic – hysterectomy
8. Psychiatric – Anxiety and depression
9. Health Maintenance – annual visit with PCP with labs, no tobacco use, no
substance abuse use.
10. Immunization status – Up to date on all immunizations. Complete
11. Dental Exams – twice yearly, cleanings
12. Last eye exam – 2025, no abnormalities found
13. SBE/Pap/GYN (include results) – hysterectomy
Family History: Include presence or absence of specific illnesses in family such as
hypertension, diabetes, or cancer
Arthritis – mother and father
Cancer- mother
Heart attack – father
Hypertension – mother
Identifying Data: Age, Gender, Occupation, and Marital Status
72 yo, female, retired, and married
Source and Reliability: Patient and medical chart
Subjective
Chief complaint or appropriate health screening visit: The one or more symptoms or
concerns causing the patient to seek care. Need not be the patient’s complete statement
– may be a brief summary of reason patient wanted to be seen for this visit
Patient’s chief complaint of ongoing cough and fatigue that has not gone
away despite prescriptions at initial visit.
HPI: Complete subjective description of problem, including “OLDCARTS” findings or
similar, including location, quality severity, duration, timing, context, modifying factors,
associated signs/symptoms, relieving and aggravating factors, related systems.
Patient states that she has been experiencing an ongoing cough and fatigue
since initial appointment on 01/08/2026 where she was diagnosed with
sinusitis and she received 100 mg doxycycline, a z-pack, and chest x ray.
Patient states she is still coughing, which is worse at night, fatigue, and
feeling hot and cold. patient states she is afebrile. Patient states that she
has had improvement in her condition but continues to experience
significant fatigue. Patient states that her cough is nonproductive. Patient
states that she does not experience wheezing or shortness of breath. Patient
states her asthma symptoms are typically triggered by illness. Patient states
that she is experiencing dizziness when taking deep breaths. She has been
using albuterol nebulizer daily, which provides some relief. patient states
that her symptoms improved while she was on steroids. Patient verbalizes
that she knows that the chest X-ray came back as lungs clear with no acute
findings in the chest. Patient reports that she is frustrated because she
cannot sleep at night due to her coughing which she believes is contributing
to the fatigue.
Medications, including OTC and Herbals Preparation
Abilify: 2 mg tablet, 1 tablet, PRN, orally, Q6H, last dose today, patient states she takes
this medication for depression
Albuterol: 2.5 mg/3 ml, daily, inhalation, last dose today, PRN, Q4H, patient states she
takes this medication for asthma
Tylenol extra strength: 500 mg, 2 tablets, PRN, orally, Q6H, last dose last week, patient
states she takes this medication for mild headaches and pain
, Aspirin: 81 mg, orally, 1 tablet, daily, last does today, patient states she takes this
medication as her blood thinner
Fluticasone: 50 mcq, nasal spray, 2 sprays, nostrils, both, daily, last dose last night,
patient states she uses this for congestion
Past Medical History:
1. Allergies – NKA
2. Childhood Illnesses – asthma
3. Adult Illnesses- anxiety and depression, cough variant asthma, osteoarthritis,
sacroiliac pain
4. Injuries- None
5. Surgeries – partial hysterectomy (7/1/2007), breast reduction (10/01/2005),
rotator cuff repair (right) (02/05/2019)
6. Hospitalizations – none
7. Obstetric/Gynecologic – hysterectomy
8. Psychiatric – Anxiety and depression
9. Health Maintenance – annual visit with PCP with labs, no tobacco use, no
substance abuse use.
10. Immunization status – Up to date on all immunizations. Complete
11. Dental Exams – twice yearly, cleanings
12. Last eye exam – 2025, no abnormalities found
13. SBE/Pap/GYN (include results) – hysterectomy
Family History: Include presence or absence of specific illnesses in family such as
hypertension, diabetes, or cancer
Arthritis – mother and father
Cancer- mother
Heart attack – father
Hypertension – mother
