After-Visit Summary
Your treatment plan and next steps from your visit
Diagnosis
Primary
Acute bronchitis (J20.9)
Secondary
Gastroesophageal reflux disease (K21.0)
Assessment: Patient presents with 3-week persistent cough and chest tightness. Exam consistent with acute bronchitis, likely post-viral. GERD suspected as contributing factor to chronic cough based on symptom pattern and response to positional changes. Recommend trial of PPI therapy and bronchodilator for symptomatic relief. Chest X-ray to rule out pneumonia or other pathology.
Treatment Plan
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Albuterol inhaler 90mcg — 2 puffs every 4-6 hours as neededFor cough and wheezing. Use before activity if symptoms triggered by exertion.Sent to CVS Pharmacy #4821
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Omeprazole 20mg — once daily for 8 weeksTake 30 minutes before breakfast. For GERD (acid reflux) and cough related to acid reflux.Sent to CVS Pharmacy #4821
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Chest X-ray (front and side view)LabCorp Imaging, 1420 Greenfield Ave. Results expected in 2-3 business days.
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Follow-up visit in 4-6 weeksTo reassess cough, review imaging results, and evaluate PPI response.
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Return sooner if symptoms worsenSeek care immediately if you experience:
Fever above 101°F • Shortness of breath at rest • Coughing up blood • Chest pain that worsens with breathing
Current Medications
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New
Albuterol 90mcg inhaler2 puffs every 4-6 hours as needed
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New
Omeprazole 20mgOnce daily, 30 minutes before breakfast, 8 weeks
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Continued
Lisinopril 10mgOnce daily
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Continued
Atorvastatin 20mgOnce nightly
Lab Orders
Chest X-ray (front and side view)
LabCorp Imaging, 1420 Greenfield Ave
CBC with differential
LabCorp, routine draw
Follow-up
Please schedule a follow-up appointment in 4-6 weeks so we can review your chest X-ray results, reassess your cough, and determine if further treatment adjustments are needed.
Book follow-upCare Team Messages
Message your care team about this visit
Not for emergencies. If you are experiencing a medical emergency, call 911.