UK General Practitioner Consultation Template

F2F seen alone. Patient presents with a persistent cough and shortness of breath.
History:
- The cough has persisted for 2 weeks, with occasional wheezing.
- ICE: Patient is worried it might be asthma and anticipates receiving medication to ease symptoms.
- No red flag symptoms such as chest pain or haemoptysis.
- Relevant risk factors include a history of smoking (10 pack-years).
- PMH: Hypertension diagnosed 5 years ago.
- DH: Currently taking Lisinopril 10mg daily. No known drug allergies.
- FH: Father had COPD.
- SH: Lives alone, works as a teacher, smokes 5 cigarettes a day, no alcohol or drug use.
Examination:
- Vital signs: T 37.2°C, Sats 95%, HR 78 bpm, BP 130/85 mmHg, RR 18 breaths/min.
- Chest examination reveals bilateral wheezing.
Impression:
1. Persistent cough. Likely diagnosis: Chronic bronchitis.
- Differential diagnosis: Asthma, COPD.
Plan:
- Investigations planned: Spirometry to assess lung function.
- Treatment planned: Prescribe Salbutamol inhaler for symptomatic relief.
- Relevant referrals: Consider referral to a respiratory specialist if symptoms persist.
- Follow up plan: Review in 2 weeks to assess response to treatment.
- Safety netting advice given: If symptoms worsen or new symptoms such as chest pain or haemoptysis develop, contact GP or call 111. In case of severe breathing difficulty, attend A&E or call 999.