Paramedic Primary Care Consultation Template

Advanced Paramedic Consultation Note Verbal consent for use of Heidi AI scribe was obtained from the patient. The patient was offered the option to opt out and declined. Chaperone was offered to the patient and declined. Presenting Complaint: Mr. John Smith, a 45-year-old male, presents today with a 3-day history of a persistent cough, shortness of breath, and a low-grade fever. He reports the cough is productive of clear sputum and worse at night. He is concerned as his breathing feels tighter than usual and he has a history of mild asthma, though he hasn't used his inhaler regularly recently. History: The patient states his symptoms began approximately 3 days ago with a dry cough that has since become productive. He describes the shortness of breath as a feeling of tightness in his chest, which is aggravated by exertion. He has tried over-the-counter cough suppressants with no relief. His last asthma exacerbation was approximately 6 months ago, for which he used his salbutamol inhaler. He has no known drug allergies. No recent travel or contact with unwell individuals. He denies chest pain, palpitations, or leg swelling. Symptoms: * Cough: Productive of clear sputum, worse at night. * Shortness of breath: Mild exertional dyspnoea, chest tightness. * Fever: Subjective low-grade, not measured. * Fatigue: Mild. * Denied: Chest pain, haemoptysis, wheezing (though noted tightness), rash, sore throat, or recent trauma. Exclusions of Red Flags: * No acute respiratory distress or signs of respiratory failure. * No evidence of stridor or significant upper airway obstruction. * No sudden onset of severe chest pain or pleuritic pain to suggest pulmonary embolism or pneumothorax. * No signs of sepsis (e.g., hypotension, altered mental status, high fever with rigors). * No unilateral leg swelling or tenderness to suggest deep vein thrombosis. Examination: * Vital Signs: HR 88 bpm, BP 130/80 mmHg, RR 18 breaths/min, SpO2 96% on room air, Temp 37.4°C. * General Appearance: Alert and oriented, appears mildly fatigued but not acutely distressed. * Respiratory: Chest expansion symmetrical. Auscultation reveals scattered rhonchi bilaterally, no crepitations or wheeze noted on forced expiration. Resonant to percussion. No accessory muscle use. * Cardiovascular: S1 S2 heard, no murmurs. Capillary refill <2 seconds. No peripheral oedema. * ENT: Oropharynx clear, no tonsillar erythema or exudates. Social: Mr. Smith works as an office administrator. He lives with his partner in a semi-detached house. He smokes 5 cigarettes per day and occasionally drinks alcohol, approximately 10 units per week. He reports no illicit drug use. He has a supportive partner at home. Plan: * Advised patient on symptomatic management for viral upper respiratory tract infection, including rest, hydration, and paracetamol for fever. * Provided patient education on asthma management, emphasising regular use of reliever inhaler if symptoms worsen and reviewing adherence to preventer if applicable. * Prescribed a 7-day course of Amoxicillin 500mg TDS, given persistent productive cough and mild chest tightness, with a low threshold for bacterial infection. (Note: This is a mock example and prescribing decisions should always follow local guidelines and clinical assessment). * Safety netting advice given: Advised patient to seek urgent medical attention if symptoms worsen significantly, develop high fever, increased shortness of breath, chest pain, or purulent sputum. * Follow-up: Recommended follow-up with GP if no improvement in 5 days or if symptoms deteriorate sooner. * Patient was provided with an information leaflet on viral respiratory infections.