GP Consult with UK guidelines

History Face to face consultation. Patient attended alone. Patient presents today with a cough and shortness of breath. Patient is concerned about the cough and is worried it might be something serious. They are hoping to get some medication to help. The cough is impacting their sleep and ability to work. Patient reports a dry cough, worse at night. No fever or chest pain. No recent travel. No known allergies. No history of asthma or COPD. No red flag symptoms. Patient is a smoker, 20 cigarettes per day for 30 years. Patient has tried over-the-counter cough medicine with no relief. Past medical history: Hypertension, controlled with medication. [examination findings] T: 37.1°C, Sats 98%, HR 88 bpm, BP 140/85 mmHg, RR 18 breaths/min. Chest auscultation: Mild wheezing in the left lung. Impression: 1. Cough. Acute bronchitis. - Rule out pneumonia. 2. Hypertension. Controlled. Plan: - Chest X-ray. - Prescribe Salbutamol inhaler 100mcg, 2 puffs as required. - Advise smoking cessation support. - Review blood pressure in 2 weeks. - Advised to call 111 if symptoms worsen or if they develop chest pain or difficulty breathing. - Follow up in 2 weeks. - Advised to seek immediate medical attention if they experience severe chest pain, difficulty breathing, or coughing up blood. Heidi notetaking used. Suggestions: Consider pneumonia as a differential diagnosis given the patient's smoking history and wheezing. The chest X-ray is appropriate. Smoking cessation advice is essential. Review blood pressure control at the follow-up appointment. Consider offering nicotine replacement therapy or referral to a smoking cessation clinic. Management of acute bronchitis is in line with NICE guidelines. No red flags were mentioned and acted upon.