Virtual Ed Kids

Clinician Specialty: General Practitioner "Telehealth consultation" "Id Check - 3 points" "Consent to AI for note taking" Parent name: Sarah Johnson Subjective - Reasons for visit and chief complaints: 4-year-old patient, Lily, presents with a persistent cough and runny nose for the past 3 days, accompanied by low-grade fever. - Duration, timing, location, quality, severity, and context of the complaint: Cough is worse at night, productive with clear mucus. Fever started yesterday, peaking at 38.2°C. No specific location for pain. Mild severity, not significantly impacting play. - Aggravating and alleviating factors: Cough worsens with lying down. Temporarily relieved by warm drinks. Paracetamol reduces fever. - Symptom progression: Started with a runny nose, followed by a cough, then the fever developed. - Past occurrences of similar symptoms: Had a similar viral infection 6 months ago, which resolved with symptomatic treatment. - Functional impact: Lily is a bit more tired than usual but is still eating and drinking well, and engaging in light play. - Associated symptoms: Occasional sneezing. No difficulty breathing, no rash, no sore throat mentioned. Past Medical History: - Past medical and surgical history: No significant past medical or surgical history. Up-to-date with routine childhood vaccinations. - Social history: Attends nursery three days a week. Lives with both parents. No pets at home. Non-smoker household. - Family history: Mother has a history of seasonal allergies. No significant family history of respiratory conditions. - Antenatal history: Uneventful pregnancy and full-term delivery. - Medications: Paracetamol (as needed for fever). - Allergies: NKDA - Immunisation history and status: All age-appropriate immunisations are up to date according to UK schedule. - Other relevant subjective information: Parent concerned about the persistent cough and potential for it to worsen. - Development: Age-appropriate development. - Pregnancy and delivery: Full-term, spontaneous vaginal delivery. No complications. Objective: - Vital signs: Temperature 37.8°C, Heart Rate 105 bpm, Respiratory Rate 24 bpm, Oxygen Saturation 98% on room air. - Weight: 18 kg (consistent with age and growth chart). - Physical or mental state examination findings: - General: Alert and interactive, though a little subdued. No signs of respiratory distress. - HEENT: Clear nasal discharge. Pharynx mildly red, no exudates. Tympanic membranes clear bilaterally. - Chest: Clear on auscultation bilaterally, no wheezes or crackles. Good air entry. - Abdomen: Soft, non-tender, no organomegaly. - Completed investigations and results: None prior to consultation. Assessment: - Likely diagnosis: Upper Respiratory Tract Infection (Viral). - Differential diagnosis: Acute bronchitis, allergic rhinitis. "Parents/carers understand the diagnosis, plan and safety netting advice." Plan: - Planned investigations: None indicated at this stage. - Planned treatment: - Reassurance to parent that this is likely a viral infection. - Continue symptomatic management with paracetamol for fever as needed. - Encourage fluid intake and rest. - Saline nasal drops for congestion. - Other relevant actions: - Advise parents on 'red flag' symptoms requiring urgent medical review (e.g., difficulty breathing, worsening fever, lethargy, rash). - Follow-up if symptoms do not improve within 5-7 days or worsen.