Class:
Phone call summary report
Date: 28 February 2019 / Time: 10:30
Contact Person: Mr. Wilson
Summary:
Mr. Wilson called in 10 a.m. this morning, with the complaint he has an
irritating cough, especially at night while asleep.
The complaints started one week ago, he said to me he makes a wheezing noise
while breathing in.
Mr. Wilson is a stubborn smoker. He has a shortness of breath while climbing
the stairs.
My advise to Mr. Wilson was that he has to call back if his condition will get
worse or when he is still having the cough in about two weeks. He was willing
to try to quit smoking. But he could not promise anything. I made him aware of
the consequences of COPD. Because he has an irritating cough at night I gave
him a prescription for cough suppressing medication. He had no shortness of
breath whilst resting and no swollen feet or ankles.
Signature/date: 28 February 2019