GP Consultation
Created by
Paul Hughes
Specialty
General Practitioner
Last edited
10/20/2026
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0 times
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About this template
A structured template for documenting general practice consultations, whether conducted in person or by telephone. It covers the presenting history, ICE and risk factors, examination and investigations, clinical impression, diagnoses, management, follow-up, referrals and safety-netting advice.
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F2F
Seen alone
New presentation of productive cough and SOB
History
- 5/7 Hx of worsening productive cough (green sputum), mild SOBOE, and subjective fevers. No improvement with OTC paracetamol.
- ICE: Worried it is a chest infection like last winter; hoping for abx.
- Red Flag: No haemoptysis, no pleuritic chest pain, no wt loss or night sweats.
- Risk Factors: Ex-smoker (20 pack-years, quit 2018), mild asthma.
- PMH/PSH: Asthma, HTN, appendicectomy (2005).
- DH: Ramipril 5 mg PO OD, salbutamol 100 mcg INH PRN.
- Allergies: Penicillin (maculopapular rash).
- FH: Father had COPD.
- SH: Lives with partner, works as an accountant, EtOH 10 u/wk, nil recreational drugs, no recent travel.
Examination
- T 37.8 °C, Sats 96 % OA, HR 92 bpm, BP 134/82 mmHg, RR 18 /min.
- Alert, talking in full sentences. Chest: coarse crackles R base, nil wheeze. CVS: HS I+II+0.
- Peak flow: 420 L/min (predicted 450 L/min).
Impression
Right basal LRTI.
- Community-acquired pneumonia
- ?Infective exacerbation of asthma
Plan
- Sputum MC&S if symptoms fail to improve after 5 days.
- Doxycycline 200 mg PO STAT on day 1, then 100 mg PO OD for 4 days (5/7 total). Advised regular paracetamol 1,000 mg PO QDS PRN and adequate fluid intake.
- Routine asthma nurse review in 1 month.
- F/U in 1/52 if cough not settling, or sooner if deteriorating.
- Safety netting advice: Call GP or 111 if fever persists > 48 hrs on abx or symptoms worsen; attend A&E/call 999 if severe SOB, chest pain, confusion, or coughing up blood.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.