Elizabeth T. OV - History of Present Illness and Assessment & Plan Template

CC: Ongoing cough and difficulty breathing
HPI: Elizabeth T. is a 45-year-old female presenting with an ongoing cough and difficulty breathing that started about two weeks ago. The symptoms have progressively worsened, especially at night, and are accompanied by mild chest discomfort. She denies having fever or chills.
The primary concern is a persistent cough, lasting for two weeks. The cough is dry and more severe at night, interrupting sleep. Elizabeth has a history of seasonal allergies but denies recent allergen exposure. She has been using over-the-counter cough syrup with little relief. A chest X-ray has been ordered to exclude any underlying issues.
The secondary concern is difficulty breathing, mainly during physical activity. This symptom began around the same time as the cough. Elizabeth has a history of mild asthma and uses an inhaler as needed, which provides some relief. Pulmonary function tests have been arranged to evaluate her current respiratory condition.
New concerns: None reported.
Assessment/Plan: 
Elizabeth T. is a 45-year-old female presenting today for evaluation of ongoing cough and difficulty breathing.
Chronic cough
- Chest X-ray ordered
- Continue using over-the-counter cough syrup
Difficulty breathing
- Pulmonary function tests scheduled
- Use inhaler as needed
"We discussed that if symptoms worsen or persist, please return to the office for further evaluation or to the ER if needed."
Dr. Thomas Smith
“Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”