🇬🇧 SystmOne & EMIS GP Consultation Template

Summary: - Mrs. Davies presented today with a cough and shortness of breath. History revealed a recent upper respiratory tract infection. Examination revealed reduced air entry bilaterally. Plan includes prescribing an inhaler and arranging a chest X-ray. T/C Seen alone. Reason for visit: Cough and shortness of breath. Consent: - Verbal consent was obtained for the use of AI Scribe software to document the consultation. History: - History of presenting complaints: Cough for 2 weeks, worsening shortness of breath for 3 days. - Current issues: Cough, shortness of breath, fatigue. - SOCRATES: Onset: 2 weeks ago, Character: Dry cough, Radiation: None, Associated symptoms: Fever, shortness of breath, Timing: Constant, Exacerbating factors: Exercise, Severity: 6/10. - Red flag symptoms: None. - Relevant risk factors: Smoker. - PMH: Asthma, Hypertension. - DH: Salbutamol inhaler, Lisinopril. Allergies: Penicillin. - FH: Father with COPD. - SH: Smoker (10 cigarettes per day), lives with husband, works as a teacher. Relevant Investigation results - Chest X-ray: Pending. Examination: - General appearance: Appears tired, but in no acute distress. - Vital signs: Temp 37.2°C, Sats 96%, HR 88 bpm regular, BP 130/80 mmHg, RR 18. - Respiratory examination: Reduced air entry bilaterally, wheezing on auscultation. Diagnosis: 1. Acute exacerbation of asthma. 2. Upper respiratory tract infection. Plan: - Prescribed Salbutamol inhaler, 2 puffs as needed. - Arrange chest X-ray. - Advised to rest and drink plenty of fluids. - Follow-up in 1 week if symptoms worsen. - Safety netting advice: Advised to seek immediate medical attention if experiencing severe shortness of breath or chest pain.