SOAP NOTE

Subjective: - Patient presents today with a three-day history of a sore throat, cough, and runny nose. She reports feeling generally unwell, with body aches and fatigue. She denies any fever or chills. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Patient's past medical history includes childhood asthma, well-controlled with an inhaler. She had a tonsillectomy at age 8. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Medications: Albuterol inhaler as needed, over-the-counter cough syrup. No known herbal supplements. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Social history: Patient is a non-smoker and drinks alcohol occasionally. She works as a teacher and lives with her husband and two children. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Allergies: No known drug allergies. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective: - Vital signs: Temperature 37.2°C, Pulse 80 bpm, Blood pressure 120/80 mmHg, Respiratory rate 16 breaths/min, SpO2 98% on room air. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Physical examination findings: Patient appears tired but is in no acute distress. Throat is erythematous with mild tonsillar exudates. Lungs are clear to auscultation bilaterally. Mild rhinorrhea present. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Laboratory and imaging results: Rapid strep test performed in office, results pending. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment: - Diagnosis or differential diagnosis: Acute pharyngitis, likely viral etiology. Possible bacterial pharyngitis. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Clinical impression: Upper respiratory infection. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: - Treatment plan, including medications, therapies, and follow-up appointments: Prescribe symptomatic treatment including rest, fluids, and over-the-counter pain relievers. If rapid strep test is positive, will prescribe antibiotics. Follow up in 3 days if symptoms worsen or do not improve. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Patient education and counseling: Educate patient on proper hand hygiene and the importance of rest and hydration. Advise patient to avoid close contact with others to prevent spread of illness. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Referrals to other healthcare providers: None at this time. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date: 1 November 2024