🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-07-27 11:30:31

Transcript

Patient: I had a fever around 100.8 degrees two nights ago, but it came down with a seat amenity. I don't really have shortness of breath unless I climb stairs, any chest pain or wheezing. No chest pain. Maybe a little wheezing last night, but it wasn't severe.
Doctor: Have you noticed a sore throat? Running nose? More sinus pressure?
Patient: My throat was swollen at the start, and now I have pressure around my cheeks and stuffy nose.
Doctor: Do you have any medical conditions? Like asthma?
Patient: I have hypertension. It's been under control.
Doctor: Work? What medications are you currently taking?
Patient: I take Amlodifen, 5mg once every morning. That's my only regular medication.
Doctor: Any medication allergies?
Patient: Yes, I'm allergic to penicillin. I get a rash.
Doctor: Do you smoke or vape?
Patient: I don't smoke. I don't smoke or vape. I have a beer once or twice a week.
Doctor: Has anyone around you been sick recently?
Patient: Yeah, a coworker had a bad cold last week.
Doctor: Have your symptoms been getting better, worse, or staying about the same?
Patient: They seemed mild at first, but the congestion and cough have definitely gotten worse.
Doctor: What you told me. This sounds most consistent with acute bacterial sinus infection, with an upper respiratory tract infection. I'd still like to examine you and recommend an X-ray. I'd also suggest a COVID-19 influenza test.
Patient: You hope that. Does it sound like the moment?
Doctor: At this point, it doesn't. Since you're not significantly short of breath, and it's less likely to be a penicillin allergy, I'll prescribe Doxycycline and Amlodifen by mouth twice daily for 7 days. For congestion, use Fenazol nasal spray with 2 sprays each nostril once daily for 14 days. It can also take quite a bit of time.
Patient: That makes sense.
Doctor: I'd like to see you again on August 10, 2026 at 1030 a.m. EST to make sure you're in good health. Does that time work for you?
Patient: Yes, August 10th at 1030 a.m. EST works for me.
Doctor: Great, I'll see you then. Take the medications as directed, and I hope you're feeling much better before this 10th at 1030 a.m. EST.

Clinical Notes

SOAP Clinical Note

Subjective

The patient reports having a fever of 100.8 degrees two nights ago, which subsided with medication. The patient does not experience shortness of breath unless climbing stairs and denies any chest pain. There was mild wheezing last night, but it was not severe. The patient initially had a swollen throat and now experiences sinus pressure around the cheeks and a stuffy nose. The patient has hypertension, which is under control, and takes Amlodifen, 5mg once every morning. The patient is allergic to penicillin, resulting in a rash. The patient does not smoke or vape and consumes alcohol occasionally. A coworker recently had a bad cold. The patient's symptoms, particularly congestion and cough, have worsened.

Objective

The patient is advised to undergo an X-ray and a COVID-19 influenza test to further assess the condition.

Assessment

The symptoms are consistent with an acute bacterial sinus infection and an upper respiratory tract infection.

Plan

  1. Prescribe Doxycycline and Amlodifen to be taken orally twice daily for 7 days.
  2. Recommend Fenazol nasal spray, 2 sprays in each nostril once daily for 14 days for congestion.
  3. Schedule a follow-up appointment on August 10, 2026, at 10:30 a.m. EST to monitor the patient's progress and ensure recovery.
  4. Advise the patient to take medications as directed and monitor symptoms.
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