Renucci Standard consult aka GOLD STANDARD

General Practitioner Consultation Note 1. describes a persistent cough Symptom duration: 3 weeks Symptom quality and severity: Dry, hacking cough, worse at night, rated 6/10 in severity. Associated symptoms: Mild shortness of breath, occasional chest tightness. Current treatments and effects: Tried over-the-counter cough syrup with minimal effect. Examination: Chest auscultation revealed clear lung sounds bilaterally. No wheezes or crackles. Temperature 37.1°C. Oxygen saturation 98% on room air. Plan: Advised rest and hydration. Prescribed a course of oral prednisolone 20mg daily for 5 days. Arrange a chest X-ray if symptoms worsen or persist for more than a week. Advised to return if any signs of pneumonia. 2. describes lower back pain Symptom duration: 2 months Symptom quality and severity: Dull ache, worse after prolonged sitting, rated 4/10 in severity. Associated symptoms: None. Current treatments and effects: Tried over-the-counter paracetamol and ibuprofen with some relief. Examination: Normal range of motion in the lumbar spine. No tenderness to palpation. Straight leg raise negative bilaterally. Neurological exam intact. Plan: Advised continued use of paracetamol and ibuprofen as needed. Recommended physiotherapy referral. Discussed ergonomic adjustments at work. Reviewed back care advice. PMHx: No significant past medical history. No known drug allergies. Regular medications: Paracetamol as needed, Ibuprofen as needed. Social and Family History: Works as an office administrator. Non-smoker. Drinks alcohol socially. Family history of osteoarthritis in mother. Examination: Blood pressure 130/80 mmHg, pulse 78 bpm, respiratory rate 16 breaths/min, temperature 37.1°C. General appearance: well-nourished and in no acute distress. Cardiovascular: Regular rate and rhythm, no murmurs. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender. Neurological: Alert and oriented. Impression: 1. Acute bronchitis. 2. Chronic lower back pain. Plan: 1. Review chest X-ray results. 2. Follow up on back pain management. 3. Continue current medications. 4. Provide patient with relevant information leaflets. 5. Schedule a follow-up appointment in 2 weeks. 6. Advised to return if any signs of pneumonia. Verbally consented to the use of AI for note-taking. Offered discussion as to pros and cons and risks of data breach and explanation to how it works.