[doctor] good alright hello hannah how are you today
[patient] i'm doing well
[doctor] you're doing well
[patient] i did have this this hacking cough for about three days now
[doctor] okay tell me more about that cough
[patient] it started three days ago i was around my sister and she has been sick with the same kind of symptoms and so this cough has just started off with like a gradual cough and now i've just been coughing up some green phlegm here
[doctor] okay okay so you you started having some mucus with it
[patient] yes
[doctor] okay and how about any other symptoms with your cough
[patient] i'm having a little bit of a sore throat here and then a little bit of a some nasal congestion as well
[doctor] okay okay and how about any fevers
[patient] i have n't had a fever yet
[doctor] no fever okay and then any shortness of breath
[patient] no shortness of breath
[doctor] no shortness of breath okay and what have you been doing for your cough
[patient] i've just been kinda drinking lots of water taking some cough medication over the counter and it seems like it's not really working
[doctor] it's not helping okay and tell me do you have any history of any seasonal allergies
[patient] right around spring time i get a little bit of sneezing and the runny runny nose
[doctor] okay okay and then any how about any body aches for you
[patient] no body aches
[doctor] nausea or vomiting
[patient] no
[doctor] okay alright so we will definitely examine you and talk more about that and as far as your diabetes how has everything been going with that checking your sugars how has that been going
[patient] i've been pretty good at checking my blood sugars they've been running around one twenty range
[doctor] okay okay and i know the metformin is a we started you on a lower dose it's the five hundred milligrams it's a new medication for you you've been tolerating it okay
[patient] yes i have n't had any problems
[doctor] okay good any diarrhea sometimes patients will say that
[patient] no diarrhea
[doctor] no diarrhea okay and then how about as far as your blood pressure
[patient] blood pressure has been a little bit high i've noticed
[doctor] okay
[patient] kind of one forties the top number
[doctor] okay
[patient] and the lower numbers seems like it's been okay around seventies
[doctor] seventy okay so a bit high and the hydrochlorothiazide have you been able to take that everyday
[patient] yes i've been taking it everyday
[doctor] okay and how about your diet how's been thing as far as salty foods
[patient] i've been trying to stay away from the salty foods but sugar intake i'm having a little bit of trouble with that
[doctor] okay okay but it seems like you've been making good progress and that could be difficult sometimes and you mentioned being around i think you said your sister a few days ago or a family member
[patient] yeah she was just kinda sick with similar symptoms and i noticed i started to developed a little bit of a cough right after
[doctor] after that okay and how is your family doing how is everyone doing other than that other than being sick for your sister how is everyone going
[patient] everyone's doing great
[doctor] okay
[patient] working busy with life yeah
[doctor] okay and for you too were you on vacation last week and a lot of people had vacation last week
[patient] yes i was on vacation last week actually
[doctor] okay hopefully you were n't sick for too much of it
[patient] no i was feeling okay
[doctor] okay okay
[patient] got back and started feeling poorly
[doctor] sorry about that alright so what i'm gon na do now is i'm gon na go ahead and start your physical exam i looking at your vitals vitals look overall pretty good i do see your blood pressure is elevated at here it's one forty four over seventy two otherwise everything else looks good so let's check you out so first starting i'm just gon na check start with your sinuses and when i press here do you have any pain any tenderness when i do that
[patient] no
[doctor] no okay so no frontal sinus tenderness how about when i press on the on your cheeks here
[patient] maybe a little bit just a little bit
[doctor] on both sides
[patient] yes
[doctor] okay so bilateral maxillary sinus tenderness alright and i'm just gon na take a look at in your mouth if you can open up okay so i do see some do have some erythema of the pharynx and the tonsils are symmetrical i do n't appreciate any exudates now i'm just checking your neck and i do appreciate some anterior cervical adenopathy alright and i'm just gon na take a listen to you alright so listening to your heart so you have a nice regular rate and rhythm and you do still have that two out of six systolic ejection murmur at the left base now i'm taking listen to your lungs and on your lungs exam okay your lungs are nice and clear i do n't appreciate any wheezes rales or rhonchi alright and just looking at your lower extremities i do n't appreciate any edema there so let's talk about my assessment and plan so for your first problem of the cough so looking at your cough it does seem like you have a upper respiratory infection and so basically that's a virus most likely it's a virus that's causing your symptoms especially being around someone else who has similar symptoms and seems like most likely they spread it to you so i want you to continue with doing a lot of the time is just letting the virus run it's course and taking things just to help with your symptoms so drinking lots of fluids that's gon na help you trying i know you've been doing a cough medicine you can even try another one you have to be careful with the blood pressure and diabetes so you can try like a coricidin hbp can help with the cough and lots of rest okay lots of rest now we are in a current pandemic and so something i can check for you if you're okay with that is checking for covid if that's okay with you
[patient] yes i'm okay with that
[doctor] okay so we will check you for that today and see how you're doing with that and then we will give you those results okay any questions about that
[patient] no questions
[doctor] no okay so for problem number two the type two diabetes so we'll continue you on your metformin five hundred milligrams daily or twice a day you had blood work at your last visit so you'll be due at your next visit for your hemoglobin a1c and that's the check the sugars on your red blood cells so we do that about every three months so at your next visit we'll check that for you and then we will go from there but it seems like you're doing well with that now as far as problem number three your high blood pressure so your blood pressure is elevated here and it sounds like it's been you know creeping up just a little bit at home as well you're on a very tiny dose of the hydrochlorothiazide so what i would like to do is increase it to twenty five milligrams once a day again i would recommend that you take it in the morning just because you may have noticed it can make you urinate quite a bit and then i would love for you to just continue checking as you have been a few times a week just checking your blood pressure at different times of the day so we can continue to see how you do with that okay
[patient] okay alright that sounds
[doctor] alright any questions for me
[patient] no questions
[doctor] okay
[patient] thank you
[doctor] thank you alright so at this point now i'm just gon na press the
[doctor] i'm gon na

Medical orders:
description: coricidin hbp
order_type: medication
reason: cough
description: hydrochlorothiazide twenty five milligrams once a day in the morning
order_type: medication
reason: high blood pressure
description: covid today
order_type: lab
description: blood next visit hemoglobin a1c
order_type: lab
reason: type two diabetes