Primary Care Visit Note

History

• Presents with a 5-day history of productive cough (green sputum), mild SOB on exertion, and subjective fevers. Denies chest pain, haemoptysis, or orthopnoea.
• Also requests a routine review of home BP readings.
• PMH: Asthma (mild intermittent), essential hypertension, Laparoscopic cholecystectomy (2018).
• DH: salbutamol 100 mcg INH PRN, amlodipine 5 mg PO OD.
• SH: Ex-smoker (stopped 2015, 10 pack-year history), 4 units alcohol/week, lives with partner, works as an accountant.
• Allergies: Penicillin (maculopapular rash).

Examination

• Vital signs: T 37.8 °C, HR 88 bpm, BP 146/92 mmHg, RR 18 /min, SpO2 96 % on room air.
• Chest: Coarse crackles at the right lung base, mild end-expiratory wheeze bilaterally, no dullness to percussion.
• CVS: HS I+II+0, JVP not elevated, no peripheral oedema.
• Investigations: Peak expiratory flow rate (PEFR) 380 L/min (predicted 450 L/min). Home BP diary average 144/88 mmHg over 7 days.

Assessment & Plan

1. Productive cough
   • Lower respiratory tract infection
   • Differential: Community-acquired pneumonia, infective exacerbation of asthma
   • Sputum MC&S; CXR if symptoms fail to improve in 48 hours
   • clarithromycin 500 mg PO BD for 5 days; increase salbutamol 100 mcg INH up to QDS PRN; safety-netting advice provided regarding worsening SOB or persistent fever
2. Hypertension
   • Suboptimally controlled essential hypertension
   • Check U&Es and HbA1c prior to medication titration
   • Increase amlodipine to 10 mg PO OD once blood results reviewed
   • Refer to Practice Nurse for repeat BP check in 4 weeks