APC template consult notes

**History** • URTI • IHD • HTN # **URTI** - Onset 3 days ago, following exposure to child with cough. - Main sx: Sore throat, rhinorrhoea, cough. Associated features: Mild fever, myalgia. - Known dx or relevant hx: Nil. - Investigations performed to date: Nil. - Prev tx: Paracetamol. # **IHD** - Onset 10 years ago. - Main sx: Occasional chest pain on exertion. - Known dx or relevant hx: Angina. - Investigations performed to date: ECG, stress test. - Prev tx: Aspirin, statin. # **HTN** - Onset 5 years ago. - Main sx: Asymptomatic. - Known dx or relevant hx: HTN. - Investigations performed to date: BP monitoring. - Prev tx: ACE inhibitor. **Other** - PMHx/PSHx: IHD, HTN, Appendectomy 2005. - FHx/SHx/Vax hx: Father – IHD. Smoker 20/day. Flu vaccine last year. **On Exam** Obs: BP 140/90 | HR 72 | T 37.2 | SpO2 98% RA HS: Dual, no murmurs. RS: Clear. **Management Plan** - Ix ordered – FBC, UEC, CRP. - Referred to Cardiology. - Follow-up in 2 weeks for results and review. - Symptomatic advice: Rest, fluids, paracetamol for fever. - Safety net advice: Seek urgent review if SOB, chest pain, or worsening symptoms.