Presenting Complaint

Cough for seven days.
SOB.

History of Presenting Complaint

Patient presents with a cough that has been present for seven days.
The cough is productive of green phlegm.
Associated SOB.

Observations

Temp 38.9
RR 20
O2 98%

On Examination

Crackles heard on the right base of the chest.
Heart sounds are normal.

Plan

Amoxicillin 500mg capsules PO TDS for 7 days.
Follow up in 48 hours.

Safety Netting

Not discussed.

Recordings

Original (A3)

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Audit

Presenting Complaint

Cough for seven days. [1]
SOB. [1][2]

History of Presenting Complaint

Patient presents with a cough that has been present for seven days. [1]
The cough is productive of green phlegm. [2]
Associated SOB. [2]

Observations

Temp 38.9 [3]
RR 20 [3]
O2 98% [3]

On Examination

Crackles heard on the right base of the chest. [4]
Heart sounds are normal. [4]

Plan

Amoxicillin 500mg capsules PO TDS for 7 days. [5][6]
Follow up in 48 hours. [7]

Safety Netting

Not discussed.

References

[1] Cough shortness of breath, cough present for seven days,

[2] productive green phlegm associated shortness of breath,

[3] examination temperature 38.9, respiratory rate of 20, oxygen 98,

[4] chest crackly on the right base, heart sounds are normal,

[5] prescribed amoxicillin 500mg,

[6] capsules, take one capsule orally three times a day for seven days,

[7] follow up for 48 hours.