Suffolk GP Federation - SystmOne Template

History: - The patient presents with a persistent cough and shortness of breath for the past two weeks. - ICE: The patient is concerned about the possibility of a chest infection and expects to receive medication to alleviate symptoms. - No red flag symptoms such as hemoptysis or significant weight loss are present. - Relevant risk factors include a history of smoking (10 pack-years). - PMH: Hypertension diagnosed 5 years ago, managed with lisinopril. - DH: Currently taking lisinopril 10mg daily. Allergies: None known. - FH: Father had COPD. - SH: Lives alone, retired, smoked for 20 years but quit 5 years ago, occasional alcohol use, no recent travel. Examination: - Vital signs: T 37.2°C, Sats 95%, HR 88 bpm, BP 130/85 mmHg, RR 18 breaths/min. - Chest examination reveals bilateral wheezing and reduced air entry in the lower lobes. - No other significant findings. Diagnosis: 1. Persistent cough and shortness of breath. Likely diagnosis: Acute bronchitis. - Differential diagnosis: Exacerbation of COPD. Plan: - Investigations planned: Chest X-ray to rule out pneumonia. - Treatment planned: Prescribe salbutamol inhaler for symptomatic relief. - Relevant referrals: None at this time. - Follow up plan: Review in 2 weeks or sooner if symptoms worsen. - Safety netting advice given: If symptoms worsen or new symptoms such as chest pain or hemoptysis develop, contact GP or call 111. In case of severe breathing difficulty, call 999.