GP Document Template

Presenting Problem(s) 1. Patient reports a persistent cough for the past three weeks, worse at night. * Cough is dry, non-productive. * Patient has been taking over-the-counter cough syrup with minimal relief. * Patient's goal is to alleviate the cough and improve sleep quality. 2. Patient reports fatigue and feeling run down. * Patient reports feeling tired most days. * Patient has been sleeping more than usual. * Patient's goal is to regain energy levels and feel more alert. Past Medical History 1. Hypertension, diagnosed in 2018, well-controlled with medication. * Patient takes Lisinopril 10mg daily. 2. Seasonal allergies. Current Medications & Allergies 1. Lisinopril 10mg, once daily, orally. 2. Cetirizine 10mg, as needed for allergies. 3. No known drug allergies. Examination 1. Temperature: 37.2°C. 2. Pulse: 78 bpm, regular. 3. Blood pressure: 130/80 mmHg. 4. Respiratory rate: 16 breaths per minute. 5. Chest auscultation: Clear to auscultation bilaterally. 6. Throat: Mildly erythematous. Impression 1. Acute upper respiratory tract infection (likely viral). 2. Possible exacerbation of seasonal allergies. 3. Controlled hypertension. Plan 1. Advised rest and increased fluid intake. 2. Continue Lisinopril 10mg daily. 3. Continue Cetirizine 10mg as needed for allergies. 4. Prescribed Dextromethorphan cough syrup, 10ml every 6 hours as needed for cough. * Advised to monitor for side effects such as drowsiness. * Advised to store at room temperature. 5. Follow-up in 1 week if symptoms worsen or do not improve. Referrals 1. None. Follow-up 1. Review in-person in 1 week (8 November 2024) to assess cough and fatigue. 2. Patient instructed to contact the practice if symptoms worsen or if any new symptoms develop.