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Chest infection – what would you do?

Chief Complaint
Brian C is a 56 year old male. The “chest infection” screening questionnaire was
administered. The following are his responses.
History of Present Illness
#1. “chest infection”
Duration
He reported: Cough 1 to 3 days.
Timing
He reported: Woken up at night by cough.
He denied: Suffering from shortness of breath during allergy season.
Severity
He reported: Able to speak full sentences between breaths.
Quality
He denied: Possible flu.
Context
He reported: Cough does not bring up phlegm from chest.
Associated Signs and Symptoms
He reported: Cough associated with fever. Shortness of breath sometimes
associated with sweating. Shortness of breath associated with chest pain.
He denied: Shortness of breath associated with numbness and lips turning blue.
Recent respiratory symptoms improved then worsened.
Past, Family, and Social History
Past Medical History
Otolaryngology
He denied: Sinus infection.
Pulmonology
He denied: Asthma.
Social History
Substance Use
Tobacco Use
History of: Previous tobacco use.
He denied: Smoking cigarettes.
Medication History
Ongoing Medications
History of: Cold and cough medications.
He denied: Cough medicines.
Review of Systems
Constitutional
He reported: Feeling feverish. Fever 1 to 2 days. Did not measure temperature when
feverish.
He denied: Chills with fever.
Eye
He reported: Eyes watering during the same season or time every year.
Ear, Nose, and Throat
He reported: Swollen glands in neck. Nasal stuffiness or congestion 3 to 4 days and not
different indoors or outdoors. Runny nose during certain seasons of the year. Constant
blocked nose.
He denied: Hearing loss. Nasal discharge down back of throat. Earache now.
Nasal stuffiness or congestion chronic. Runny nose. Sore throat. Facial pain.
Cardiovascular
He reported: Sometimes has feeling of suffocation when lying flat.
He denied: Chest pain spread to the left arm or shoulder. Chest pain spread to the
neck, jaw, or teeth. Chest pain spread to the back.
Musculoskeletal
He reported: Muscle pain.
Neurologic
He reported: Headaches caused by illness. Headaches sometimes associated with
neck stiffness.
He denied: Headaches accompanied by vomiting. Headaches severe. Severe pain
bending chin to chest.
Risk Factors, Prevention, and Patient Issues
Patient Issues
He denied: Needing excuse from work.
Comments
chest feels tight in sternum region, feverishness mostly at night. Feel I can’t breathe deeply or as easily as usual rather than really breathless – unless I try to move vigorously

GPs, what would you do first?

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