🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-09-10 20:09:12
Transcript
Doctor: Hi, I'm Dr. Dasty. What brings you into the ER today? Patient: Hey, Dr. Dasty. I'm coming in because I have a really bad sore throat. It feels like knives. Doctor: Knives? Okay, so it's a sharp pain. How long have you had that? Patient: Like two weeks. Doctor: Any problems swallowing? Patient: Yeah, definitely. It's been hurting to swallow. I've been drinking, like, just having soup and stuff. Doctor: Okay, so you can still swallow. It just hurts a lot. Patient: Yeah. Doctor: Okay. What have you taken for that? Patient: Just, you know, normally, I don't really know what to take for that, but I take, like, pain medication, like ibuprofen. Doctor: Okay, so you've been taking ibuprofen? Patient: Yeah. Doctor: All right. Any cough or congestion? Patient: Yeah, I definitely have congestion and, like, a little bit of a cough, like, a lot of, like, phlegm in my throat, but... Doctor: When did the cough start? Patient: Just a couple days after the sore throat. Doctor: Any fever? Patient: I don't think so, but I feel like I have chills, and I haven't checked. I don't have a... I don't have anything to check in my house. Doctor: Well, it looks like you had a fever today, 100.4. Patient: That makes sense. Doctor: Okay. Any nausea, vomiting, diarrhea? Patient: Like a little bit of nausea. I think that... Yeah, I've just been feeling a little sick recently. Doctor: Any abdominal pain? Patient: Um, no, not really. Doctor: Any neck stiffness? Patient: Sometimes. Doctor: Okay, no rash anywhere? Patient: No, that I know of, no. Doctor: When you said you get neck stiffness, I mean, you're able to move your neck okay? It just feels a little bit sore? Patient: Yeah, it's sore. Doctor: Okay. Yeah. All right. Do you take any medications? Patient: Yeah, I take, like, birth control, and sometimes I take, like, Adderall. Doctor: Okay, so Adderall you don't take every day? Patient: No, not really. Doctor: Got it. All right. Okay. Any history of asthma or allergies? Patient: Um, no, I don't think so. Never done an allergen test. Doctor: Okay, but you don't have, like, hay fever, seasonal allergies? No? Patient: No. Oh, actually, yeah, I get, like, sneezy. Doctor: Sometimes? Or all the time? Patient: Just sometimes. Only on seasonal change. Doctor: All right. And anyone around you sick? Patient: I don't think so, but I'm not too sure. I travel on the subway a lot. Doctor: Oh, okay. All right. So you could have easily picked something up. All right. Well, let's take a quick look. So let's start with your mouth. Just open your mouth wide, and let's take a look in there. Oh, yeah, your tonsils look enlarged, and they're a little bit red. Looks like you also have some kind of white spots on the back there. Let's check your neck. Sounds like... All right. I feel some lymph nodes on the right side. Your ears look fine. Your lungs are clear. Your heart's regular. Your abdomen is non-tender. Okay. All right. So let's check a strep test. We'll give you some ibuprofen for the fever and pain, and then I will be back in. Patient: Okay.
Clinical Notes
SOAP Note
Subjective:
- Chief Complaint: Sore throat
- History of Present Illness: Patient reports a sharp sore throat described as feeling like knives for two weeks. The sore throat is associated with pain on swallowing, congestion, a little cough, and phlegm in the throat. The patient has been taking ibuprofen for pain relief. She reports chills and nausea but has not checked her temperature at home.
- Past Medical History: No significant past medical history reported.
- Medications: Birth control, occasional Adderall, ibuprofen for pain.
- Allergies: Reports seasonal allergies, gets sneezy during seasonal changes.
- Social History: Patient travels frequently on the subway.
Objective:
- Vitals: Fever noted at 100.4°F.
- Physical Exam:
- Mouth: Tonsils enlarged and red with white spots.
- Neck: Lymph nodes palpable on the right side.
- Ears: Normal.
- Lungs: Clear.
- Heart: Regular.
- Abdomen: Non-tender.
Assessment:
- Pharyngitis: Likely viral or bacterial given the sore throat, fever, and tonsillar findings.
Plan:
- Medications: Continue ibuprofen for fever and pain relief.
- Diagnostics: Perform a strep test to rule out streptococcal infection.
- Lifestyle Modifications: Encourage rest and hydration.
- Follow-up: Return for further evaluation if symptoms persist or worsen.