Persistent cough and nasal congestion for three days.
HISTORY OF PRESENT ILLNESSPatient reports a dry cough, stuffy nose, mild fatigue, and occasional wheezing. Symptoms are worse at night. Denies fever, chest pain, or shortness of breath.
RELEVANT HISTORYNo history of asthma or chronic lung disease reported. Taking an over-the-counter cough suppressant. No known medication allergies.
REVIEW OF SYSTEMSPositive for congestion, cough, and fatigue. Negative for fever, sore throat, chest pain, and difficulty breathing.
ASSESSMENTUpper respiratory symptoms, most consistent with a viral illness. Patient appears comfortable and in no acute distress.
PLANDiscussed hydration, rest, and symptom monitoring. Follow up if symptoms worsen or do not improve. Return precautions reviewed.
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