New Patient (custom)

Subjective: - Reason for visit: Patient presents today with a chief complaint of a persistent cough and shortness of breath for the past two weeks. - Current GP: Dr. Emily Carter at the Riverside Clinic. - Symptom details: Cough is dry and hacking, worse at night. Shortness of breath occurs with minimal exertion. No chest pain. - Aggravating and relieving factors: Cough is aggravated by cold air and exercise. Relieved slightly by rest. - Progression: Symptoms have gradually worsened over the past two weeks. - Previous episodes: Patient reports a similar cough last winter, which resolved with rest and over-the-counter medication. - Impact on daily activities: Shortness of breath limits ability to walk the dog and perform household chores. - Associated symptoms: Mild fatigue. Past Medical History: - Contributing medical/surgical history: Asthma diagnosed at age 10, well-controlled with inhaler. No surgeries. - Relevant social history: Non-smoker. Drinks alcohol occasionally. Works as a teacher. - Relevant family history: Mother has a history of asthma. - Exposure history: No known environmental exposures. - Immunisation history/status: Up-to-date with flu and COVID-19 vaccinations. - Other relevant information: Patient is concerned about the possibility of pneumonia. - Obstetric/menstrual history: Not applicable. - Bowel health: Regular bowel movements. - Sleep: Reports difficulty sleeping due to coughing. - Metabolic health: No known metabolic concerns. - Chronic pain: No chronic pain. - Histamine-related conditions: Occasional seasonal allergies. - Diet: Balanced diet. - Work: Works as a teacher. - Hobbies: Enjoys gardening. Objective: - Vitals: Temperature 37.2°C, Pulse 88 bpm, Respirations 20/min, BP 130/80 mmHg, SpO2 96% on room air. - Examination findings: Chest auscultation reveals mild wheezing in the left lung. No other significant findings. - Investigations with results: Chest X-ray: No evidence of pneumonia. Spirometry: FEV1 75% predicted. Assessment: - Likely diagnosis: Exacerbation of asthma. - Differential diagnosis: Bronchitis, upper respiratory tract infection. Plan: - Investigations planned: Repeat spirometry in 2 weeks. - Treatment planned: Increase in inhaled corticosteroid dose. Prescribe a short course of oral steroids. Advise on asthma action plan. - Other actions: Provide patient education on asthma management. Schedule follow-up appointment in 2 weeks. Advise patient to return if symptoms worsen. Date: 1 November 2024