General Patient Note - Small issue

General Practitioner Date: 1 November 2024 68y/o female, now with signs and symptoms consistent with an acute upper respiratory tract infection with associated cough. Medical History: # Hypertensive: Well controlled on Amlodipine 5mg OD with no known target-organ-damage. Latest BP 130/80 mmHg. # Type 2 Diabetes Mellitus: Poorly controlled on Metformin 500mg BD. Latest HbA1c 8.2%. # Allergies: Penicillin (rash and hives) Presenting Complaint: Patient now presents with a productive cough, headache, and general malaise for the past three days. The cough is worse at night and produces clear sputum. Associated symptoms include a mild sore throat and nasal congestion. Important negatives include no shortness of breath, chest pain, or fever. Symptoms are mildly alleviated by warm fluids and exacerbated by cold air. Social History: Patient is a retired teacher, lives with her husband. Non-smoker, occasional alcohol use. Enjoys gardening. Family Medical History: # Father: Deceased at 72 from myocardial infarction. History of hypertension and hyperlipidaemia. # Mother: Alive, 90, with osteoarthritis. Physical examination: BP: 140/85 mmHg HR: 78 bpm SATS: 98% on room air T: Apyrexic HGT: 7.2 mmol/L Hb: N/A General appearance: Appears stable with no jaundice, pallor, cyanosis, clubbing, lymphadenopathy, or distress at rest. Average build. Respiratory system: Good air entry bilaterally, no adventitious sounds heard. Patient comfortable on room air, no signs of respiratory distress. Cardiovascular system: S1 S2 dual rhythm, no murmurs or rubs. Peripheral pulses present and equal in all four limbs, no delay. Abdominal system: Abdomen soft and non-tender, no organomegaly or masses palpable. Neurological system: GCS 15/15, PEARL, fully oriented. No cranial nerve fallout, no focal or global motor or sensory fallout. Assessment: Acute upper respiratory tract infection, likely viral, with associated productive cough. Patient’s Type 2 Diabetes Mellitus remains poorly controlled. Plan: 1. Biochemistry requested: Full blood count, C-reactive protein, Urea & Electrolytes. 2. Imaging requested: Nill 3. Counselled on: Hydration, rest, symptom management with paracetamol for headache and sore throat. Advised on signs of worsening infection (e.g. shortness of breath, fever, purulent sputum) and when to return. Discussed importance of diabetic control and advised on dietary modifications. 4. Management initiated: Paracetamol 500mg PRN for pain/fever (acute) Simple linctus for cough (acute) 5. Patient to return: If symptoms worsen or no resolution by 8 November 2024, or if blood test results are significantly abnormal. Tasks to be created: Review blood test results when available. Refer to Diabetic Nurse for education and management review.