Consultation Template Generator

Consultation Template
CHILDREN
Attends with Mum
6 week check

SVD Section, Breast Bottle Mixed feeding, Exam: Red reflexes N, heart N, femoral pulses N, Hips Barlow and Ortolani N, Genitalia N, Testes descended

6 week check.

SVD Section, Contraception XXX, No problems

Attends with Mum Dad

Viral Cough

XXX days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse XXX, resp XXX , sats XXX , temp XXX , chest clear ,

Imp: URTI

Plan: Reassured viral.

Worsening statement

ALMOND GROUP PRACTICE. Seek further help if short of breath, wheezy, temperature over 39 after paracetamol and ibuprofen or drowsiness. Please read the following: https://tinyurl.com/mwt98nys

Attends with Mum Dad

Cough

Cough XXX days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse XXX, resp XXX , sats XXX , temp XXX , chest clear ,

Imp: Community acquired pneumonia

Plan: Treat with antibiotics

Worsening statement

ALMOND GROUP PRACTICE. Seek further help if short of breath, wheezy, temperature over 39 after paracetamol and ibuprofen or drowsiness. Please read the following: https://tinyurl.com/mwt98nys

Attends with Mum Dad

Cough Wheeze SOB

XXX days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse XXX, resp XXX , sats XXX , temp XXX , chest creps wheeze bibasally,

 

Plan: Treat with antibiotics and steroids

Worsening statement

ALMOND GROUP PRACTICE. Seek further help if more short of breath or wheezy, temperature over 39 after paracetamol and ibuprofen or drowsiness. Please read the following: https://www.asthma.org.uk/advice/

Attends with Mum Dad

Cough

XXX days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse XXX, resp XXX , sats XXX , temp XXX , chest creps and wheeze bilaterally bibasally,

Imp: Bronchiolitis

Plan: Explained viral eitiology but can sometimes require hospitalisation. Advised inhalers not helpful. 

Worsening statement

ALMOND GROUP PRACTICE. Seek further help if worsening short of breath or wheeze, temperature over 39 after paracetamol and ibuprofen or drowsiness. Please read the following: https://www.nhs.uk/conditions/bronchiolitis/

Attends with Mum Dad

Cough

XXX days, dry bark. No SOB, no wheeze. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse XXX, resp XXX , sats XXX , temp XXX , chest clear.

Imp: Croup

Plan: Steroids

Explained viral eitiology but can sometimes require hospitalisation. 

Worsening statement

ALMOND GROUP PRACTICE. Seek further help if worsening short of breath, temperature over 39 after paracetamol and ibuprofen or drowsiness. Please read the following: https://www.nhs.uk/conditions/croup/

Attends with Mum Dad
Sore throat

XXX days, No Cough. Eating drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse XXX , resp XXX , sats XXX , temp XXX , throat red tonsils normal no exudate, chest clear ,

Centor  – XXX

Imp: Viral

Plan: Reassured viral
Worsening statement

ALMOND GROUP PRACTICE. Seek help if unable to manage fluids, a temperature of over 39 despite regular paracetamol and ibuprofen, drowsiness. https://tinyurl.com/mwt98nys

Attends with Mum Dad

Tonsillitis

Sore throat XXX days. No SOB, no wheeze. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse XXX , resp  XXX, sats XXX , temp XXX  , chest clear , no tender lymphadenopathy, throat – red, enlarged, exudative tonsils.

Centor – XXX

Plan: Treat with antibiotics

Worsening statement

ALMOND GROUP PRACTICE. Seek help if unable to manage fluids, a temperature of over 39 despite regular paracetamol and ibuprofen, drowsiness. https://tinyurl.com/mwt98nys

Attends with Mum Dad

Painful ear

Painful XXX ear XXX days. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse  XXX, resp XXX, sats XXX, temp XXX, chest XXX, throat XXX, left ear XXX, right ear XXX

Imp: Left Right Otitis media

Plan: Treat with antibiotics. Advised regular paracetamol and ibuprofen. Advised may burst. 

ALMOND GROUP PRACTICE. Further information: https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/middle-ear-infection-otitis-media. When to seek further help: https://tinyurl.com/mwt98nys

ADULT

Depressive Episode

Low mood XXX weeks, No alcohol or drugs. No suicidal ideation. Work, family, exercise. Affect normal.

Plan:

Crisis numbers

Self Help

Exercise

ALMOND GROUP PRACTICE: If you have serious thoughts of taking your life please phone the practice 8-6pm Monday-Friday or phone the out of hours GPs on 111 otherwise. Please explore your local NHS services here: https://www.almondgrouppractice.scot.nhs.uk/selfref/mhealth/

Acute on Chronic Back Pain

00 days 00 weeks,

Came on when …,

sleep,

Sciatica left right leg, no tingling or numbness between legs. Bladder and bowel function normal

Imp:

Plan:

Go straight to A+E if any tingling or numbness between legs, difficulty passing urine or new urine or bowel leaking.

Exacerbation of Asthma

Cough Wheeze SOB days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. Smoker Nonsmoker On exam: Well , cap refill 2, lips moist, pulse XXX, resp XXX , sats XXX , temp XXX , chest creps wheeze bibasally,

Plan: Treat with antibiotics and steroids

Worsening statement

ALMOND GROUP PRACTICE. Seek further help if more short of breath or wheezy, temperature over 39 after paracetamol and ibuprofen or drowsiness. Please read the following: https://www.asthma.org.uk/advice/

.

Exacerbation of COPD

Cough Wheeze SOB days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. Smoker Nonsmoker On exam: Well , cap refill 2, lips moist, pulse XXX, resp XXX , sats XXX , temp XXX , chest creps wheeze bibasally,

Plan: Treat with antibiotics and steroids

Worsening statement

ALMOND GROUP PRACTICE. Seek further help if more short of breath or wheezy, temperature over 39 after paracetamol and ibuprofen or drowsiness. Please read the following: https://www.blf.org.uk/support-for-you/copd

Joint injection of XXX

8 week short term benefits and risks discussed including infection, flare and skin atrophy. 40 mg in 1 ml Kenalog expiry XXX batch XXX. Can be repeated every 3 months as necessary.

Sinusitis

No nasal discharge XXX days, no fevers, facial pain. Has tried XXX

On exam: Well, tender facial sinuses, temp XXX, pulse XXX,

Imp: Viral Sinusitis.

Plan: Analgesia

Try steroid nasal spray

Worsening statement – 2 weeks, purulent discharge, fevers

Sinusitis

Purulent nasal discharge XXX days, fevers, facial pain. Has tried XXX

On exam: Well, tender facial sinuses, temp XXX, pulse XXX,

Imp: Bacterial Sinusitis.

Plan: Analgesia, antibiotics

Try steroid nasal spray

Worsening statement –

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