UCC Appt SOAP Note

Subjective: - Patient presents with a persistent cough and sore throat for the past week. Reports mild fever and fatigue. No significant history of similar complaints. - Past medical history includes hypertension and type 2 diabetes. Previous appendectomy in 2015. - Current medications include Lisinopril 10mg daily and Metformin 500mg twice daily. No herbal supplements reported. - Social history: Non-smoker, occasional alcohol use, works as a school teacher. - Allergies: Penicillin. Objective: - Vital signs: BP 130/85 mmHg, HR 78 bpm, Temp 99.1°F, RR 16 breaths/min. - Physical examination findings: Mild erythema in the throat, no cervical lymphadenopathy, clear lung sounds. - Laboratory and imaging results: Rapid strep test negative, CBC shows mild leukocytosis. Assessment: - Diagnosis: Viral pharyngitis. - Clinical impression: Likely viral etiology given negative strep test and mild symptoms. Plan: - Treatment plan: Recommend rest, increased fluid intake, and over-the-counter analgesics such as acetaminophen for fever and throat pain. Follow-up in one week if symptoms persist. - Patient education and counseling: Advised on the importance of hydration and rest. Educated about signs of worsening symptoms that would require immediate medical attention. - Referrals to other healthcare providers: None at this time.