General Practitioner Consult (custom)
F2F seen alone. Patient presents with a persistent cough and shortness of breath.
History:
- The cough has been ongoing for 2 weeks, with occasional wheezing.
- ICE: Patient is concerned it might be pneumonia and expects to receive antibiotics.
- No red flag symptoms such as chest pain or fever.
- Relevant risk factors include a history of smoking.
- PMH: Asthma, diagnosed at age 10.
- DH: Currently taking Salbutamol inhaler as needed. No known drug allergies.
- FH: Father with a history of COPD.
- SH: Smokes 10 cigarettes per day.
Examination:
- Vital signs: Temperature 37.2°C, Pulse 88 bpm, BP 130/80 mmHg, SpO2 96% on room air.
- Chest examination reveals mild wheezing bilaterally.
Impression:
1. Acute exacerbation of asthma.
- Differential diagnosis: Pneumonia, bronchitis.
Plan:
- Investigations: Chest X-ray to rule out pneumonia.
- Treatment planned: Prescribe Prednisolone 40mg daily for 5 days and increase Salbutamol inhaler use.
- Relevant referrals: None.
- Follow up plan: Review in 1 week, or sooner if symptoms worsen.
- Safety netting advice given: Advised to seek immediate medical attention if experiencing severe shortness of breath, chest pain, or difficulty breathing.
F2F seen alone. Patient presents with [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History:
- The cough has been ongoing for [duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), with occasional wheezing.
- ICE: Patient is concerned it might be [patient concern] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) and expects to receive [patient expectation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- No red flag symptoms such as [red flag symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- Relevant risk factors include a history of [risk factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- PMH: [Past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- DH: Currently taking [medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). No known drug allergies.
- FH: [Family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- SH: [Social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
Examination:
- Vital signs: [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- Chest examination reveals [chest examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
Impression:
1. [Primary impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- Differential diagnosis: [Differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
Plan:
- [Investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- Treatment planned: [Treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- Relevant referrals: [Referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- Follow up plan: [Follow up plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
- Safety netting advice given: [Safety netting advice] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
(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 that the information has not been explicitly mentioned in your output. Leave the relevant placeholder or section blank if it is not explicitly mentioned. Use as many full sentences as needed to capture all the relevant information from the transcript.)
