Patient presents today with a three-day history of a worsening cough, accompanied by a runny nose and a mild headache. She reports feeling generally unwell and fatigued. She denies any fever or chills. The patient reports that the cough is dry and non-productive.
The cough is primarily located in the chest. It is exacerbated by talking and lying down. The patient reports that rest and over-the-counter cough medicine provide some relief. The headache is mild, located in the frontal region, and does not radiate. The patient rates the pain as a 3/10. The symptoms are affecting her ability to sleep and concentrate at work.
The patient has no significant past medical history. She denies any previous surgeries.
No weight loss, no chest pain, no shortness of breath, no trauma.
The patient is a non-smoker. She drinks alcohol occasionally, about one or two units per week. She denies any recreational drug use.
The patient is fit to drive.
The patient is employed full-time as a teacher. She has a supportive network of friends and family.
The patient reports feeling frustrated by her illness but denies any symptoms of anxiety or depression. No suicidal thoughts.
The patient is currently taking paracetamol for her headache and cough medicine.
No investigations were performed today.
The patient lives with her partner and has a good support system.
The patient has no known allergies.
The patient is concerned about the duration of her symptoms and whether she might have a more serious illness.
The patient is worried about missing work and the potential impact on her students.
The patient expects to receive advice on how to manage her symptoms and whether she needs any further treatment.
Vitals: Temperature 37.1°C, Pulse 80 bpm, BP 120/70 mmHg, SpO2 98% on room air. General: The patient appears tired but is in no acute distress. Chest: Clear to auscultation bilaterally. Throat: Mildly erythematous. No lymphadenopathy.
No investigations were performed today.
1. Upper Respiratory Tract Infection.
Common cold, influenza, or other viral infection.
No investigations are planned at this time.
Advised rest, adequate hydration, and over-the-counter pain relief and cough medicine. Advised to self-isolate if symptoms worsen.
Continue paracetamol as needed for pain and fever. Cough medicine as directed. Advised to monitor for side effects.
No referrals are needed at this time.
Advised to return if symptoms worsen or do not improve within a week.
Advised to seek immediate medical attention if she develops difficulty breathing, chest pain, or high fever.
A leaflet on managing upper respiratory tract infections will be sent to the patient.
Date: 1 November 2024
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