Main template GP consult

Verbally consented to the use of AI for note-taking as per Avant. Offered discussion as to pros and cons and risks of data breach and explanation of how it works. History: 1. Complaining of a cough for the past week. Symptom quality and severity: Dry cough, mild severity. Symptom duration: One week. Associated symptoms: Sore throat. 2. Patient reports feeling fatigued for the past two weeks. Symptom quality and severity: Constant fatigue, moderate severity. Symptom duration: Two weeks. Associated symptoms: Difficulty concentrating. Past history: Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments: No significant past medical history. Family history: Relevant past family history and social history: Father with hypertension. Examination: Findings from the physical examination, including vital signs and any abnormalities: Chest clear to auscultation. Vital signs listed, eg. T , Sats %, HR , BP , RR , (as applicable): BP 130/80. Impression: 1. Cough. Assessment, likely diagnosis for Issue 1: Likely viral upper respiratory tract infection. 2. Fatigue. Assessment, likely diagnosis for Issue 2: Possible iron deficiency. Plan: - Advised rest and fluids for the cough. - Recommended paracetamol for symptomatic relief. - Ordered a full blood count to investigate fatigue.