General Practitioner Clinical Encounter
Reason for Appointment: The patient presents today with a cough and fever. They report feeling generally unwell and have been experiencing these symptoms for the past few days.
Duration and Onset of Symptoms: The cough started 3/7 ago, and the fever began 2/7 ago.
Self-Care Measures: The patient has been taking paracetamol for the fever and drinking plenty of fluids.
Past Medical History: The patient has a history of seasonal allergies.
Current Medications: Paracetamol 500mg as needed.
Allergies: No known allergies.
Travel History: The patient has not travelled recently.
Social History: The patient is a non-smoker and drinks alcohol occasionally.
Level of Distress: The patient reports a moderate level of distress due to the symptoms.
Examination Findings: Temperature 38.5°C, mild cough, clear lungs on auscultation.
IMP: Likely viral upper respiratory tract infection.
Advice/Instructions: Advised the patient to continue taking paracetamol for fever, rest, and drink plenty of fluids. Advised to seek further medical attention if symptoms worsen or if they develop any new symptoms.
Follow-up Plans: Advised to return if symptoms do not improve within a week. No referrals made.
Date: 1 November 2024
[describe the reason for the appointment, including symptoms and concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[mention the duration and onset of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[describe any self-care measures taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[mention any relevant past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[mention current medications and dosages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[mention any known allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[describe any recent travel history or exposure to infectious diseases] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[mention any relevant social history, including smoking, alcohol, and drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[describe the patient's level of distress or anxiety] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
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IMP: [mention any differential diagnosis given to the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
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[describe any follow-up plans or referrals made] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(refer to days in 1/7 format, i.e. one day is 1/7, two days is 2/7; refer to weeks in 1/52 format, i.e. one week is 1/52, two weeks is 2/52; refer to months in 1/12 format, i.e. one month is 1/12, two months is 2/12, and so on) (refer to years as normal text, i.e. 1 year, 2 years, 3 years, and so on)
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