Consult General

Consult General General Practitioner 1 November 2024 Problem List 1. Hypertension: Controlled with medication. 2. Type 2 Diabetes Mellitus: Managed with diet and oral medication. 3. Osteoarthritis: Affecting both knees, managed with analgesics and physiotherapy. 4. Anxiety: Mild, managed with lifestyle modifications and occasional counselling. Presented with The patient, a 68-year-old male, presents today with a three-day history of a worsening cough and shortness of breath. The cough is dry and non-productive, and the shortness of breath is exacerbated by exertion. He denies fever, chest pain, or any recent travel. He reports a history of similar episodes in the past, usually resolving within a week. On examination General appearance: The patient appears his stated age and is in mild respiratory distress. Vital signs: Temperature 37.2°C, Pulse 90 bpm, Respirations 22/min, Blood pressure 140/88 mmHg, SpO2 94% on room air. Chest auscultation reveals scattered wheezes bilaterally. No other significant findings on examination. Impression Based on the history and examination, the most likely diagnosis is an exacerbation of chronic obstructive pulmonary disease (COPD). Differential diagnoses include pneumonia and acute bronchitis. The patient's history of similar episodes and the presence of wheezes support the diagnosis of COPD exacerbation. Plan. 1. Administer a salbutamol inhaler (2 puffs every 4 hours as needed for shortness of breath). 2. Prescribe a course of oral prednisolone 30mg daily for 5 days. 3. Advise the patient to continue his usual COPD medications. 4. Instruct the patient to monitor his symptoms and return to the clinic if there is no improvement or if symptoms worsen. 5. Schedule a follow-up appointment in one week to review his condition and adjust his treatment plan if necessary.