Consultation Template Generator Consultation Template CHILDREN 6 week check – Child Viral Cough Community Acquired Pneumonia Bronchiolitis Croup Exacerbation of Asthma Viral sore throat Tonsillitis Otitis Media – Antibiotics Otitis Media – No antibiotics Gastroenteritis …..Attends with Mum6 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 ……Attends with Mum Viral Cough XXX days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. No rash. On exam: Well child, cap refill 2, lips moist, pulse 90 , resp 25 , sats 98 , temp 37.0 , 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 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 90 , resp 25 , sats 98 , temp 37.0 , chest – coarse creps LEFT RIGHT base, 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 Cough Wheeze SOBXXX days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse 90 , resp 25 , sats 98 , temp 37.0 , chest creps wheeze bibasallyPlan: 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 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 90 , resp 25 , sats 98 , temp 37.0 , chest creps and wheeze bilaterally, 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 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 90 , resp 25 , sats 98 , temp 37.0 , chest clear. Imp: Croup Plan: Steroids Explained viral eitiology but can sometimes require admission. ======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 Sore throat XXX days, No Cough. Eating drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse 90 , resp 25 , sats 98 , temp 37.0 , throat red tonsils normal no exudate, chest clear , Centor – XXX Imp: Viral Plan: Reassured viral. Advised regular analgesia and fluids. ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Seek help if unable to manage fluids, a temperature of over 39 despite regular paracetamol and ibuprofen, drowsiness or struggling to swallow fluids. https://tinyurl.com/mwt98nys …..Attends with Mum 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 90 , resp 25 , sats 98 , temp 37.0 , chest clear , tender cervical lymphadenopathy, throat – red, enlarged, exudative tonsils. Centor – XXX Plan: Treat with antibiotics. Regular analgesia and fluids. ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Seek help if unable to manage fluids, a temperature of over 39 despite regular paracetamol and ibuprofen, drowsiness or unable to swallow fluids. https://tinyurl.com/mwt98nys …..Attends with Mum RIGHT LEFT Otitis Media Painful XXX ear XXX days. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse 90 , resp 25 , temp 37.0 , chest clear , throat red , left ear XXX , right ear XXX Plan: Treat with antibiotics. Advised regular analgesia. Advised may burst. ======WORSENING STATEMENT========= 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 …..Attends with Mum RIGHT LEFT Otitis Media Painful XXX ear XXX days. Eating and drinking fine. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse 90 , resp 25 , temp 37.0 , chest clear , throat red , left ear XXX , right ear XXX Plan: Advised child well and likely viral. Advised regular analgesia. Advised may burst. ======WORSENING STATEMENT========= 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 …..Attends with Mum Gastroenteritis Diarrhoea and vomiting XXX days. Passing urine. On exam: Well child, cap refill 2, lips moist, pulse 90 , resp 25 , temp 37.0 , chest clear , abdo soft nontender. Plan: Advised child not dehyrated and likely viral. ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Get back in touch if temperature > 39 despite paracetamol or ibuprofen, blood in poo, not passing urine in > 4 hours, dry lips, drowsy or not keeping fluids down. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/gastroenteritis ADULT Depression Neurology Exam Back Pain Cough – Viral Cough – Bacterial Exacerbation of Asthma Exacerbation of COPD Sore throat – Viral Tonsillitis Ear Pain Joint Injection Sinusitis – Viral Sinusitis – Bacterial …..Depressive Episode Low mood XXX weeks, No alcohol or drugs. No suicidal ideation. Work, family, exercise. Affect normal. Plan: Self Help, Exercise =========WORSENING STATEMENT========= 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 lower Back Pain XXX days XXX weeks, started on when XXX . Sleeping fine. No fevers. No history of cancer. No sciatica, no tingling or numbness between legs. Bladder and bowel function normal. Imp: mechanical back pain Plan: Analgesia, Back stretching exercises, Physio ============WORSENING STATEMENT========== ALMOND GROUP PRACTICE. Here are some back exercises for your to try. https://tinyurl.com/2cpzzk8f Go straight to A+E if any tingling or numbness between legs, difficulty passing urine or new urine or bowel leaking. …..Viral Chest infection Cough XXX days, dry productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. Smoker Nonsmoker On exam: Well , cap refill 2, lips moist, pulse 80 , resp 16 , sats 98 , temp 37.0 , chest clear Plan: Reassured. Advised viral ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Seek further help if more short of breath or wheezy, temperature over 39 after paracetamol and ibuprofen or drowsiness. https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/chest-infection …..Community Acquired Pneumonia Cough XXX days, productive. No SOB, no wheeze. Eating and drinking fine. Passing urine. Smoker Nonsmoker On exam: Well , cap refill 2, lips moist, pulse 80 , resp 16 , sats 98 , temp 37.0 , chest – creps LEFT RIGHT base Plan: Treat with antibiotics ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Seek further help if more short of breath or wheezy, temperature over 39 after paracetamol and ibuprofen or drowsiness. https://www.nhsinform.scot/illnesses-and-conditions/lungs-and-airways/pneumonia …..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 80 , resp 16 , sats 98 , temp 37.0 , 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 80 , resp 16 , sats 98 , temp 37.0 , 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 …..Viral Sore throat XXX days, No Cough. Eating drinking fine. Passing urine. On exam: Well , cap refill 2, lips moist, pulse 80 , resp 16 , sats 98 , temp 37.0 , throat red tonsils normal no exudate, chest clear , Centor – XXX Imp: Viral Plan: Reassured viral. Advised regular analgesia and fluids. ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Seek help if unable to manage fluids, a temperature of over 39 despite regular paracetamol and ibuprofen, drowsiness or struggling to swallow fluids. https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/sore-throat …..Tonsillitis XXX days, No Cough. Eating drinking fine. Passing urine. On exam: Well , cap refill 2, lips moist, pulse 80 , resp 16 , sats 98 , temp 37.0, chest clear, throat – red enlarged tonsils with exudate. Uvula central. Centor XXX Plan: Treat with antibiotics. Advised regular analgesia and fluids. ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Seek help if unable to manage fluids, a temperature of over 39 despite regular paracetamol and ibuprofen, drowsiness or struggling to swallow fluids. https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/tonsillitis …..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 37.0 , pulse 80 , Imp: Viral Sinusitis. Plan: Analgesia Try steroid nasal spray ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Please get back in touch if things haven’t settled in 2 weeks time, if you have profuse green snot, or ongoing fevers despite paracetamol and ibuprofen. https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/sinusitis …..Sinusitis Purulent nasal discharge XXX days, fevers, facial pain. Has tried XXX On exam: Well, tender facial sinuses, temp 37.0 , pulse 80 Imp: Bacterial Sinusitis. Plan: Analgesia, antibiotics Try steroid nasal spray ======WORSENING STATEMENT========= ALMOND GROUP PRACTICE. Please get back in touch if you have ongoing fevers >39 despite paracetamol and ibuprofen. https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/sinusitis © 2022 Kristian Turnbull CAPTCHA If you are human, leave this field blank. Submit
