GP Clinic Note (custom)

GP Clinic Note (custom) Consent: Patient provided verbal consent for examination and discussion of treatment plan. Subjective: Patient presents with a 3-day history of productive cough, yellow-green sputum, and mild shortness of breath, particularly on exertion. Reports associated fatigue and a low-grade fever, peaking at 37.8°C. Denies chest pain or wheezing. Symptoms began after attending a large social gathering. Has been self-medicating with paracetamol with limited relief. Past Medical History: Diagnosed with mild asthma in childhood, managed with salbutamol inhaler PRN, last used approximately 5 years ago. No other significant medical history. No previous surgeries. Current Medications: Paracetamol 500mg as needed for fever/pain. Salbutamol inhaler (as above). Social History: Smokes 5 cigarettes per day for the last 10 years. Occasional alcohol consumption (2-3 units per week). Works as an office administrator. Lives with partner. No recent travel abroad. Allergies: Penicillin (rash). Objective: General: Appears mildly unwell but in no acute distress. Vitals: Temp 37.5°C, HR 88 bpm, RR 18 breaths/min, BP 128/78 mmHg, SpO2 96% on room air. Chest: Auscultation reveals coarse crackles at lung bases bilaterally, more prominent on the right. No wheeze. Good air entry throughout. Percussion resonant. No tenderness on palpation. Throat: Mild erythema of the pharynx. No tonsillar exudates. Assessment & Plan: 1. Acute Bronchitis - Clinical Assessment: Based on history of productive cough, fever, and crackles on auscultation, acute bronchitis is the most likely diagnosis. Viral aetiology is common, but bacterial superinfection considered given sputum colour. - Planned Investigations: None immediately indicated. Consider chest X-ray if symptoms worsen or fail to improve within 5-7 days, or if concerns for pneumonia develop. Consider sputum culture if symptoms are persistent or severe. - Planned Treatment: Advised patient on symptomatic relief including increased fluid intake, rest, and continued paracetamol for fever/discomfort. Prescribed a course of Amoxicillin-Clavulanic Acid 500/125mg three times a day for 7 days, given history of productive yellow-green sputum and smoking, to cover potential bacterial infection. Advised on proper inhaler technique for salbutamol if experiencing increased shortness of breath. - Referrals: None at this stage. Advised patient to return if symptoms worsen, develop severe shortness of breath, chest pain, or high fever. 2. Smoking Cessation - Clinical Assessment: Patient expresses some interest in reducing smoking due to current respiratory symptoms. - Planned Investigations: N/A - Planned Treatment: Provided information on local smoking cessation services and advised on benefits of quitting. Discussed various options including nicotine replacement therapy. Encouraged patient to consider a quit date. - Referrals: Offered referral to NHS Stop Smoking Service, which patient accepted. Date: 1 November 2024