Primary Care Consultation Note

Summary

F2F consultation; patient seen alone presenting with a 4-day history of right-sided pleuritic chest pain and productive cough. Examination revealed right basal crackles, mild tachycardia, and fever, consistent with community-acquired pneumonia. Commenced on oral amoxicillin and paracetamol, requested sputum MC&S and repeat CXR in 6 weeks, and provided strict red-flag safety-netting advice.

Consent

• Verbal consent obtained from patient for the use of AI scribe software during this consultation.

History

• Presenting with a 4-day history of productive cough (rust-coloured sputum) and chest pain. Site: Right lower lateral chest wall. Onset: Sudden onset 4 days ago following a mild coryzal illness. Character: Sharp, stabbing, pleuritic. Radiation: Nil. Associations: Fever, rigors, mild SOB on exertion, and myalgia. Time course: Constant background ache with sharp exacerbations, progressively worsening over 48 hours. Exacerbating and relieving factors: Exacerbated by deep inspiration and coughing; partially relieved by shallow breathing and paracetamol. Severity: 7/10 at peak.
• Denies haemoptysis, night sweats, or unintentional weight loss. No recent long-haul travel, no prolonged immobility, and no personal or family history of VTE/PE.
• PMH / PSH: Hypertension, T2DM, appendicectomy (2012), osteoarthritis of the right knee.
• DH: Amlodipine 5 mg PO OD, metformin 1,000 mg PO BD, paracetamol 1,000 mg PO QDS PRN; Allergies: NKDA.
• FH: Father had MI aged 68; mother has T2DM; no FH of respiratory malignancy or thromboembolism.
• SH: Lives with wife, independent, no carers or POC, works as an accountant, ex-smoker (quit 10 years ago, 15 pack-year history), alcohol 10 units/week, denies illicit drug use, no recent travel.

Relevant Investigation Results

• 12-lead ECG performed in surgery today: Sinus tachycardia at 102 bpm, normal axis, no acute ST-T wave changes.
• Bloods (10/05/2024): HbA1c 52 mmol/mol, eGFR > 90 mL/min/1.73m², FBC and LFTs NAD.
• Right knee X-ray (12/01/2024): Mild medial compartment joint space narrowing and osteophytosis.
• Urine dipstick today: Blood negative, nitrites negative, leucocytes trace.

Examination

• Alert, oriented, flushed, mildly tachypnoeic at rest, speaking in full sentences.
• Temp 38.2 °C, Sats 95 %, HR 102 bpm regular, BP 138/84 mmHg, RR 20 breaths/min.
• HS I+II+0, JVP not elevated, capillary refill < 2 seconds, calves soft and non-tender bilaterally, no peripheral oedema.
• Trachea central, decreased chest expansion on the right, dullness to percussion at the right base, coarse inspiratory crackles and bronchial breathing over the right lower zone, no wheeze.
• Abdomen soft, non-tender, no organomegaly, bowel sounds normal.
• Pharynx mildly erythematous, tonsils normal with no exudate, no cervical lymphadenopathy.
• Right lateral chest wall non-tender to palpation (pain is deep/pleuritic, not reproducible on palpation), normal ROM in upper limbs.
• Moving all 4 limbs equally, gross neurology intact, no focal neurological deficit.
• Warm and clammy to touch, normal skin turgor, no rashes or cyanosis.

Diagnosis

1. Right basal community-acquired pneumonia (CRB-65 score 0)
2. Type 2 diabetes mellitus
3. Pulmonary embolism (low clinical probability), viral pleurisy

Plan

• Start amoxicillin 500 mg PO TDS for 5 days. Continue paracetamol 1,000 mg PO QDS PRN for pain and pyrexia. Advised to maintain good oral fluid intake, rest, and temporarily withhold metformin if developing dehydration or vomiting (sick day rules).
• GP review F2F or via T/C in 48–72 hours if symptoms are failing to improve.
• Counselled on expected recovery timeline (cough and fatigue may take 3–4 weeks to fully resolve) and the importance of completing the antibiotic course.
• Sputum sample sent for MC&S today. Requested follow-up CXR in 6 weeks to ensure radiological resolution given smoking history.
• Advised to call 999 or attend A&E immediately if experiencing worsening SOB, breathlessness at rest, haemoptysis, confusion, drowsiness, or chest pain that becomes crushing or central. Advised to contact the practice or NHS 111 if fever persists beyond 48 hours of antibiotic therapy.