🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-30 13:24:00

Transcript

[00:00 → 00:07] Good morning, Mr. Smith. Please have a seat. What brings you into it?
[00:07 → 00:13] Morning, doctor. I have been feeling pretty rough for the last couple of days.
[00:13 → 00:20] I think I might have the flu. I see. Can you tell me about your symptoms?
[00:20 → 00:28] Well, it started with a really bad headache and body ache, especially in my back and legs.
[00:28 → 00:34] Then, the fever kicked in. I was up to 102 for and high last night.
[00:34 → 00:41] And I have got this persistent cuff mostly dry. Any fatigue or weakness?
[00:41 → 00:50] Oh, definitely. I feel completely drained. Just getting out of bed this morning was a struggle.
[00:50 → 00:54] And I have had chills too, on and off.
[00:54 → 01:00] What about short throat or runny nose? A bit of short throat, yes.
[01:00 → 01:06] And my nose has been a little stuffy. But the aches and fever are the worst patch.
[01:06 → 01:10] I haven't had much appetite either.
[01:10 → 01:18] Okay, Mr. Smith. Based on your describing, the certain onset of fever, body aches, cuff and fatigue,
[01:18 → 01:21] it sounds consistent with influenza.
[01:21 → 01:27] You can do a quick swap test to confirm if you would like, but the symptoms are fairly classic.
[01:27 → 01:33] For now, the most important things are rest and plenty of fluids.
[01:33 → 01:41] Right. That's what I figured out. Is there anything I can take for the fever and aches?
[01:41 → 01:51] Yes, over the counter medications like ibuprofen or acetaminophen can help manage those.
[01:51 → 01:54] Make sure you follow the dosage instructions.
[01:54 → 01:59] We'll discuss if an antiviral medication might be appropriate for you.
[01:59 → 02:02] Have a good day.

Clinical Notes

Subjective

  • Patient: Mr. Smith.

  • Primary Concern: Feeling unwell with symptoms suggestive of the flu.

    • Started with a severe headache, body aches in the back and legs.

    • Developed a fever up to 102 degrees Fahrenheit.

    • Persistent dry cough, fatigue, weakness, chills, sore throat, and nasal congestion.

    • Decreased appetite.

Objective

  • Medical History: Not provided.

  • Behavioral Observations: Not provided.

Assessment

  1. Influenza: Symptoms of sudden onset fever, body aches, cough, fatigue, and sore throat are consistent with influenza.

Plan

  1. Symptomatic Treatment:

    • Recommend rest and increased fluid intake.

    • Suggest over-the-counter medications like ibuprofen or acetaminophen for fever and body aches, following the dosage instructions.

    • Discuss the possibility of antiviral medication if deemed appropriate.

  2. Follow-Up:

    • Advise monitoring symptoms and seeking medical attention if condition worsens or does not improve.
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