NHS GP Style

F2F consult. Clinically relevant information from the most recent History in the timeline of events relating to the presenting issues or complaints: patient presented today with a cough and sore throat, which started three days ago. Unwell: patient reports feeling unwell. Head: patient reports a headache. Throat: patient reports a sore throat. Patient's Ideas, Concerns and Expectations to be written without a separate heading or name: patient is concerned about the cough and sore throat. No red flag symptoms relevant to the presenting complaints to be written without a separate heading or name: no chest pain. Relevant risk factors to be written without a separate heading: patient is a smoker. Past medical history or Surgical history to be written without a separate heading or name: patient has a history of asthma. Drug history and Medications to be written without a separate heading or name: patient is currently taking salbutamol inhaler. Allergies to be written without a separate heading or name: NKDA. Relevant family history and Social history to be written without a separate heading or name: patient's mother has a history of diabetes, and patient smokes 10 cigarettes a day. _Examination_: Vital signs listed, eg. Temperature , oxygen level or Sats %, HR , BP , RR , blood glucose/blood sugar/BM (only include for 'F2F' visit or consultation if applicable and explicitly mentioned and expressed as 'numericals', otherwise leave blank.): Temp 37.8°C, HR 88 bpm, BP 130/80 mmHg, Sats 98% on room air. Physical or mental state examination findings, including system specific examination (only include for 'F2F' visit or consultation, otherwise leave blank.): throat is erythematous, tonsils are enlarged. _Impression:_ Issue, problem or request 1, 2, 3, 4, 5, etc (issue, request or condition name only): Cough and sore throat. Assessment, likely diagnosis for Issue 1, 2, 3, 4, 5, etc (condition name only) (include only if applicable and explicitly mentioned in the transcript or contextual notes, otherwise leave blank.): Upper respiratory tract infection. _Plan:_ Investigations planned for Issue 1, 2, 3, 4, 5 etc (include only if applicable and explicitly mentioned, otherwise leave blank.): None. Treatment planned for Issue 1, 2, 3, 4, 5 etc (include only if applicable explicitly mentioned, otherwise leave blank.): Advised rest and fluids. Follow up plan including any actions required (noting timeframe if stated or applicable and if mentioned): review in one week if symptoms worsen. Worsening advice given include only as 'Worsening advice given-' (for example, if mentioned, state which symptoms would mean they need to call back GP or call 111 (non life threatening) for out of hours GP or if deteriorates to attend A&E/call 999 in life threatening emergency (include only the advice/options which are mentioned in transcript or contextual notes): Worsening advice given- if develops chest pain, difficulty breathing, or high fever, attend A&E.