🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-06-05 21:04:29

Transcript

[00:00 β†’ 00:01] μ•Œμ•„μš”.
[00:01 β†’ 00:02] λ¬Όλ‘ μž…λ‹ˆλ‹€.
[00:02 β†’ 00:07] μ•„λž˜λŠ” μŠˆκ·Έμ΄μ‚¬μ™€ ν™˜μž 간에 ν•œκ΅­μ–΄ λŒ€ν™”ν•  수 μžˆμŠ΅λ‹ˆλ‹€.
[00:07 β†’ 00:11] μ•ˆλ…•ν•˜μ„Έμš”. μ–΄λ””κ°€ λΆˆνŽΈν•˜μ‹ κ°€μš”?
[00:11 β†’ 00:15] μ•ˆλ…•ν•˜μ„Έμš”. μš”μ¦˜ 기침이 μ‹¬ν•˜κ³  열이 μžˆμ–΄μš”.
[00:15 β†’ 00:18] μ–Έμ œλΆ€ν„° 그런 증생성이 μžˆμ—ˆλ‚˜μš”?
[00:18 β†’ 00:21] 3일 μ „λΆ€ν„°μš”. 그리고 λͺ©λ„ μ•„νŒŒμš”.
[00:21 β†’ 00:25] μ•Œκ² μŠ΅λ‹ˆλ‹€. μ±„μš΄μ„ 제고 청진해 λ³΄κ² μŠ΅λ‹ˆλ‹€.
[00:25 β†’ 00:29] 열이 38.5λ„λ„€μš”. κ°κΈ°λ‚˜ 독감을 κ°€λŠ₯성이 μžˆμ–΄μš”.
[00:29 β†’ 00:31] 약을 λ¨Ήμ–΄μ•Ό ν•˜λ‚˜μš”?
[00:31 β†’ 00:34] λ„€. ν—€μ—΄μ œμ™€ 기침약을 μ²˜λ°©ν•΄ λ“œλ¦΄κ²Œμš”.
[00:34 β†’ 00:38] 물을 많이 λ§ˆμ‹œκ³  ν‘Ή μ‰¬μ„Έμš”.
[00:38 β†’ 00:40] κ°μ‚¬ν•©λ‹ˆλ‹€. μ €λŠ” 생λͺ…μ΄μ—μš”.
[00:40 β†’ 00:42] λΉ λ₯Έ μΌ€μ΄λΈ”μž…λ‹ˆλ‹€.
[00:42 β†’ 00:49] ν•„μš”ν•˜μ‹œλ©΄ μ–΄λ¦°μ΄μš© 비격식체 버전 λ˜λŠ” μ’€ 더 κΈ΄λŒ€ν™”λ„ λ§Œλ“€μ–΄ λ“œλ¦΄ 수 μžˆμ–΄μš”.

Clinical Notes

Subjective

  • Patient: Complains of severe cough and fever for the past 3 days. Also, experiencing throat pain.

Objective

  • Vital Signs: Temperature of 38.5Β°C.

Assessment

  1. Upper Respiratory Tract Infection: Likely diagnosis due to symptoms presented.

Plan

  1. Medications:

  2. Prescribe antipyretic and cough medicine.

  3. General Recommendations:

  4. Advise to drink plenty of water and get plenty of rest.
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