General Practitioner Consult (custom)

General Practitioner Consult (custom) F2F seen alone. Patient presents with a persistent cough and shortness of breath. History: - The cough has been ongoing for 2 weeks, with occasional wheezing. - ICE: Patient is concerned it might be pneumonia and expects to receive antibiotics. - No red flag symptoms such as chest pain or fever. - Relevant risk factors include a history of smoking. - PMH: Asthma, diagnosed at age 10. - DH: Currently taking Salbutamol inhaler as needed. No known drug allergies. - FH: Father with a history of COPD. - SH: Smokes 10 cigarettes per day. Examination: - Vital signs: Temperature 37.2°C, Pulse 88 bpm, BP 130/80 mmHg, SpO2 96% on room air. - Chest examination reveals mild wheezing bilaterally. Impression: 1. Acute exacerbation of asthma. - Differential diagnosis: Pneumonia, bronchitis. Plan: - Investigations: Chest X-ray to rule out pneumonia. - Treatment planned: Prescribe Prednisolone 40mg daily for 5 days and increase Salbutamol inhaler use. - Relevant referrals: None. - Follow up plan: Review in 1 week, or sooner if symptoms worsen. - Safety netting advice given: Advised to seek immediate medical attention if experiencing severe shortness of breath, chest pain, or difficulty breathing.