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Patient reports cough for 3 days, temperature up to 38.2 °C. Auscultation reveals crackles on the right side. Positive smoking history. CRP test ordered. Observation recommended.

S – Subjective: Patient reports cough lasting approximately 3 days and elevated body temperature up to 38.2 °C. General weakness noted. Smoking history positive. O – Objective: Body temperature 38.1 °C. Crackles heard on auscultation in the right lung field. No other significant objective findings. A – Assessment: Clinical signs consistent with an acute respiratory tract infection. Additional laboratory evaluation required. P – Plan: Perform CRP test. Provide symptomatic care. Monitor patient condition. Re-evaluation based on test results.

Visit summary During today’s visit, your symptoms of cough and fever were assessed. The examination showed signs that may indicate a respiratory infection. Next steps: a blood test (CRP) will be performed to better understand the infection rest and monitoring of your condition are recommended If fever increases, shortness of breath appears, or your condition worsens, please seek medical attention immediately.

Referral to specialist The patient was evaluated for persistent cough and fever. Auscultation revealed crackles in the right lung field. Initial investigations have been performed. Specialist consultation is requested for further evaluation and management planning.