General Practitioner's Note

History: - Patient presents with a persistent cough and mild fever for the past week. No significant improvement with over-the-counter medications. - Past medical history includes asthma diagnosed at age 10, managed with inhalers. - Currently taking Salbutamol inhaler as needed. - Non-smoker, occasional alcohol use. - Allergic to penicillin. Examination: - Temperature: 37.8°C, Heart rate: 88 bpm, Blood pressure: 120/80 mmHg - Respiratory examination reveals wheezing in the lower lobes bilaterally. - No signs of respiratory distress. - Chest X-ray ordered, results pending. Assessment & Plan: 1. Persistent cough - Likely diagnosis: Viral upper respiratory tract infection - Differential diagnosis: Bacterial pneumonia - Investigations planned: Awaiting chest X-ray results - Treatment planned: Prescribe a course of amoxicillin (if not allergic) or alternative antibiotic due to penicillin allergy - Relevant referrals: None at this time 2. Asthma management - Likely diagnosis: Asthma exacerbation - Differential diagnosis: None - Investigations planned: None - Treatment planned: Increase frequency of Salbutamol inhaler, consider adding a corticosteroid inhaler - Relevant referrals: Referral to pulmonologist for asthma management review 3. General health check - Likely diagnosis: General health maintenance - Differential diagnosis: None - Investigations planned: Routine blood tests - Treatment planned: Continue current medications - Relevant referrals: None