Primary Care Physician's Record Template

History:
- Patient reports a persistent cough and mild fever persisting for the past week, with no notable improvement from over-the-counter medications.
- Past medical history includes asthma diagnosed at age 10, managed with inhalers.
- Currently using Salbutamol inhaler as needed.
- Non-smoker, occasional alcohol consumption.
- Allergic to penicillin.
Examination:
- Temperature: 37.8°C, Heart rate: 88 bpm, Blood pressure: 120/80 mmHg
- Respiratory examination shows wheezing in the lower lobes on both sides.
- No evidence of respiratory distress.
- Chest X-ray ordered, awaiting results.
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