Standard GP Consult Template

Seen alone. **History:** - The patient presents today with a 2-week history of a worsening cough, productive of yellow sputum, and associated with shortness of breath, especially on exertion. She reports feeling generally unwell with fatigue and a low-grade fever. - The patient is here today to discuss her cough, which started after a recent cold. She is concerned about the severity of her symptoms and wants to rule out pneumonia. She reports a worsening cough, productive of yellow sputum, and associated with shortness of breath, especially on exertion. She reports feeling generally unwell with fatigue and a low-grade fever. - Pain is present in the chest, described as a sharp, stabbing pain that worsens with coughing. It is located in the right side of the chest. The pain is intermittent, occurring several times a day, and lasts for a few minutes each time. It is not relieved by rest or medication. - Haemoptysis. - Smoker. - None. **Relevant Investigations:** - Chest X-ray performed today, results pending. - Full blood count performed today, results pending. B/G - Asthma, Hypertension. Meds - Salbutamol inhaler, Amlodipine. FH - Father with history of COPD, Mother with history of asthma. SH - Lives with husband, non-smoker, drinks alcohol socially, works as a teacher, no recent travel, no carers. **Examination:** - The patient appears to be in mild respiratory distress, but is alert and oriented. - Temp 37.8°C, Sats 96%, HR 88 bpm and regular, BP 130/80 mmHg, RR 20. - No murmurs, rubs, or gallops. - Reduced air entry in the right lower lobe, with scattered wheezes. - Soft, non-tender abdomen. - No abnormalities noted. - No abnormalities noted. - No abnormalities noted. - No abnormalities noted. **Diagnosis:** 1. Pneumonia. 2. Asthma exacerbation. 3. Bronchitis, COPD. **Plan:** - Prescribed antibiotics (Amoxicillin 500mg three times a day for 7 days). Continue Salbutamol inhaler as needed. Advised to rest and drink plenty of fluids. Review in 2 weeks. - Follow-up appointment in 2 weeks. Advised to seek immediate medical attention if symptoms worsen, including increased shortness of breath, chest pain, or high fever. - Provided education on the importance of completing the course of antibiotics and the signs and symptoms of pneumonia. Counseled on smoking cessation. - Chest X-ray and full blood count ordered. - Advised to return immediately if experiencing worsening symptoms, such as increased shortness of breath, chest pain, or high fever.