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.
Problem List
[summarize the patient's current active and resolved medical, surgical, and psychiatric conditions, and any significant social issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with brief descriptions.)
Presented with
[document the patient's chief complaint and the history of the presenting illness, including onset, duration, character, relieving/exacerbating factors, and associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
On examination
[detail findings from relevant physical examinations, including general appearance, vital signs, and system-specific findings pertinent to the chief complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Impression
[provide a concise summary of the patient's condition, including differential diagnoses and the most likely diagnosis, supported by findings from the history and examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Plan.
[outline the proposed management plan, including investigations, treatments (pharmacological and non-pharmacological), referrals, and follow-up arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)