DG Family Physician note

Pt informed and consented to use of Heidi AI Scribe to facilitate this visit. Anonymized recording, no private information saved other than this visit note. **Subjective:** - Patient presents today with a three-day history of a sore throat, cough, and runny nose. Reports feeling generally unwell with fatigue. No fever reported. - **PMH** (if applicable) - Nil known - **Medications** (if applicable) - Paracetamol as needed - **Social history** (if applicable) - Non-smoker, drinks alcohol occasionally. Works as an accountant. - **Allergies** (if applicable) - NKDA **Objective:** - Temp: 37.2°C, BP: 120/80 mmHg, HR: 80 bpm, RR: 16 breaths/min, SpO2: 98% on room air. - General: Patient appears tired but is in no acute distress. - ENT: Mildly erythematous pharynx. No tonsillar exudates. Mild nasal congestion. - Chest: Clear to auscultation bilaterally. **Assessment:** 1. Upper Respiratory Tract Infection - Assessment, likely diagnosis for Issue 1 (condition name only) - Viral upper respiratory tract infection. - Differential diagnosis for Issue 1 (only if applicable) - Bacterial pharyngitis, influenza. **Plan:** Diagnosis discussed with pt. - Investigations planned for Issue 1 (only if applicable) - None required. - Treatment planned for Issue 1 (only if applicable) - Advised rest, fluids, and paracetamol for symptomatic relief. - Relevant referrals for Issue 1 (only if applicable) - None. 2. Nil - Assessment, likely diagnosis for Issue 2 (condition name only) - N/A - Differential diagnosis for Issue 2 (only if applicable) - N/A - Investigations planned for Issue 2 (only if applicable) - N/A - Treatment planned for Issue 2 (only if applicable) - N/A - Relevant referrals for Issue 2 (only if applicable) - N/A 3. Nil - Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only) - N/A - Differential diagnosis for Issue 3, 4, 5 etc (only if applicable) - N/A - Investigations planned for Issue 3, 4, 5 etc (only if applicable) - N/A - Treatment planned for Issue 3, 4, 5 etc (only if applicable) - N/A - Relevant referrals for Issue 3, 4, 5 etc (only if applicable) - N/A Heidi AI Scribe visit note reviewed, edited as needed and verified for accuracy.