Medicolegal template 2

Location of Assessment: GP surgery Subjective - Presenting complaint and duration: Patient presents with a three-day history of a sore throat and cough. - Associated symptoms: Patient reports a runny nose and mild headache. Denies fever, chest pain, or shortness of breath. - Past medical/surgical history: Nil of significance. - Current medications and allergies: No current medications. No known allergies. - Social or travel context: Patient is a non-smoker and drinks alcohol occasionally. No recent travel. Objective - Vital signs: Temperature 37.2°C, Pulse 80 bpm, BP 120/80 mmHg, SpO2 98% on room air. - General condition: Patient appears well and in no acute distress. - Focused exam findings: Mildly erythematous pharynx. No tonsillar exudates. Clear lungs to auscultation. - Red flags excluded: No signs of sepsis, pneumonia, or other serious illness. - Prior investigations discussed: No prior investigations discussed. Assessment - Working diagnosis: Upper respiratory tract infection. - Differential diagnoses: Viral pharyngitis, common cold. - (Include reasoning if uncertain: "No current red flags to suggest need for immediate escalation") Plan - Treatment given: Advised rest, fluids, and paracetamol for symptomatic relief. - (State consent if given: "Verbal consent obtained after discussion of benefits and side effects") - Follow-up plan: Advised to return if symptoms worsen or if new symptoms develop. - Safety-netting: Advised to seek immediate medical attention if experiencing difficulty breathing, chest pain, or high fever. - Referral: No referral required. - Capacity: Patient has capacity. - Companion: Patient attended the appointment alone. - Travel advice: No travel advice given.