GP Consultation Note

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History

1. Presents with a persistent cough and mild shortness of breath on exertion. Cough is productive of yellow sputum and is moderate in severity, disturbing sleep. Symptoms have been present for 5 days. Preceded by a coryzal illness 1 week ago following exposure to unwell grandchildren. Associated with subjective fevers and wheeze, but denies haemoptysis, chest pain or orthopnoea. Trialled paracetamol (Panadol®) 1,000 mg PO QID with minimal relief of fevers, and salbutamol (Ventolin®) 200 mcg INH PRN with temporary improvement in wheeze.

2. Requests a repeat prescription for regular antihypertensive medication. Asymptomatic with home blood pressure readings averaging 130/80 mmHg. Has been taking the current regimen for 2 years. No recent dizzy spells or syncopal episodes. Denies ankle swelling, headaches or visual changes. Currently taking perindopril (Coversyl®) 5 mg PO daily with good blood pressure control.

Past History

History of mild asthma, hypertension and laparoscopic cholecystectomy in 2018. Previous dry cough with ramipril, and gastrointestinal upset with erythromycin.

Family History

Father had ischaemic heart disease at age 65, and mother had type 2 diabetes mellitus. Ex-smoker (10 pack-year history, ceased 2010), drinks 2 standard units of alcohol per week, and lives at home with spouse.

Examination

Mildly increased work of breathing when speaking in full sentences. No cyanosis, no accessory muscle use, no cervical lymphadenopathy, and calves are soft and non-tender. Temp 37.8 °C, SpO2 95 % on room air, HR 88 bpm regular, BP 134/82 mmHg, RR 18 breaths/min. Chest auscultation reveals scattered expiratory wheezes bilaterally and coarse crepitations at the right lung base, with dual heart sounds and no murmurs.

Impression

1. Acute lower respiratory tract infection with mild exacerbation of asthma. Likely community-acquired pneumonia (right basal) triggering reactive airways. Differential diagnosis includes acute viral bronchitis or infective exacerbation of undiagnosed COPD.

2. Essential hypertension. Stable and well-controlled on current monotherapy. No suspicion of secondary hypertension or end-organ damage.

Plan

Aim to treat the lower respiratory tract infection empirically, relieve bronchospasm, and maintain current antihypertensive therapy.

• Commence amoxicillin (Amoxil®) 500 mg PO TID for 5 days, increase salbutamol (Ventolin®) 100 mcg INH to 2–4 puffs QID via spacer, and review in 48 hours or attend the emergency department immediately if shortness of breath worsens.
• Provided repeat prescription for perindopril (Coversyl®) 5 mg PO daily and advised to continue monitoring home blood pressure readings.