GP notes

History - Patient presents today with a 3-day history of a worsening cough, accompanied by a runny nose and mild fever. The cough is productive, with yellow-green phlegm. No chest pain or shortness of breath reported. No history of asthma or allergies. Patient denies any recent travel or contact with anyone who is unwell. - Past medical history: Nil known. No previous surgeries. - Social history: Non-smoker. Drinks alcohol occasionally. Works as a teacher. - Patient expresses concern about the duration of the cough and wants to rule out pneumonia. - Patient also reports feeling tired and generally unwell. Examination: T 37.8°C, HR 88 bpm, RR 16 breaths/min, Sats 98% on room air. Impression - Upper respiratory tract infection, likely viral. Possible secondary bacterial infection. Plan: - Advised to rest, stay hydrated, and take paracetamol for fever and discomfort. - Prescribed antibiotics (Amoxicillin 500mg three times a day for 7 days) for suspected secondary bacterial infection. - Patient education: Explained the importance of completing the antibiotic course. Advised on cough etiquette (covering mouth and nose when coughing or sneezing) and hand hygiene. - Safety netting advice: Advised to seek medical attention if symptoms worsen, such as difficulty breathing, chest pain, or high fever, or if symptoms do not improve after 3 days. Advised to call back if concerned.