NHS GP Consultation

F2F consult in context to above online request. Patient was reviewed for right lower zone respiratory symptoms and a recent acute cough. Previous history entry from 10/04/2026 shows a 1-week history of dry cough managed with OTC meds. Cough; started 5 days ago, productive of green mucus, worse at night. Temperatures; started 3 days ago, intermittent, shivery episodes. Breathing; SOB on exertion when walking upstairs, worse over the last 2 days. Chest; lateral chest pleuritic type pain on the right side for 2 days, worse on coughing. Patient is concerned about a lower respiratory tract infection and expects antibiotics. no haemoptysis, no SOB at rest, no stridor, no retrosternal pain, no palpitations, no postural dizziness, no pedal oedema, no calf swelling. Risk factors include current smoking of 10 cigarettes per day. Past medical history includes hypertension, T2DM, CKD Stage 3A, and previous cholecystectomy. Current medication includes amlodipine 5 mg PO OD, metformin 500 mg PO BID, and paracetamol 1,000 mg PO QID PRN. NKDA. Father had an MI, mother had T2DM, patient lives with partner, works as an office administrator, drinks 4 units of alcohol per week. Previous U&E + eGFR on 12/01/2026 showed eGFR 52 mL/min/1.73m² (CKD Stage 3A), FBC NAD, LFT NAD.

Examination

Temperature 37.8 °C, Sats 96 %, Pulse 92, BP 134/82 mmHg, RR 18, BM 6.4 mmol/L. Respiratory examination showed coarse crackles at the right base, equal air entry on the left, no wheeze, and trachea central. Cardiac examination showed normal heart sounds, regular rhythm, and no peripheral oedema. ENT examination showed pharynx normal, no erythema, and tympanic membranes normal bilaterally.

Impression

1. Productive cough and pleuritic type pain. Community-acquired pneumonia.
2. Acute bronchitis, pulmonary embolism.

Plan

1. Blood testing and chest X-ray planned.
2. Treatment plan includes amoxicillin 500 mg PO TID for 5 days, alongside rest, oral fluids, and regular analgesia.
3. No referral required at this stage. Clinical review in 48 hours if no improvement, or routine follow-up in 6 weeks for repeat chest X-ray to ensure resolution. Contact the GP if symptoms fail to improve after 3 days, call 111 for a non-life-threatening out-of-hours problem, or attend A&E/call 999 in the event of severe SOB at rest, haemoptysis, confusion, or acute deterioration.