Clerking

C/c Patient presents today with a three-day history of a worsening cough, described as dry and hacking, with no associated sputum production. The cough is more frequent at night and is aggravated by lying down. The patient denies any fever, chills, or shortness of breath, but reports mild fatigue and a scratchy throat. PMHX The patient has a history of seasonal allergies, managed with over-the-counter antihistamines. No other significant past medical history is reported. Social history The patient is a non-smoker and drinks alcohol occasionally, approximately one to two units per week. They are employed as a teacher and live with their partner in a two-bedroom flat. Medications and allergies The patient is currently taking loratadine 10mg once daily for allergies. No known drug allergies. NEWS Respiration Rate: 16 breaths/min, Oxygen Saturation: 98% on room air, Systolic Blood Pressure: 120/78 mmHg, Pulse Rate: 80 bpm, Level of Consciousness: Alert, Temperature: 37.1°C. NEWS score: 0. O/E General appearance: Alert and oriented. Mildly flushed face. Chest auscultation reveals clear lung fields bilaterally with no wheezes or crackles. Throat is mildly erythematous. No lymphadenopathy. Blood No blood tests were performed during this visit. Imaging No imaging studies were performed during this visit. Impression Likely viral upper respiratory tract infection (URTI). Plan. Advised to rest, stay hydrated, and take over-the-counter cough suppressants as needed. Reassurance given. Advised to return if symptoms worsen, or if they develop a fever, shortness of breath, or chest pain. Follow-up in one week if symptoms persist. Advised to self-isolate if they test positive for any respiratory viruses.