DIALOGUE

[doctor] hi teresa what's going on i heard that i heard that you're having a sore throat you're not feeling well
[patient] yeah my throat has been hurting me for like four four days now and i think i had a fever last night because i was really sweaty but i did n't take my temperature because i was already in bed
[doctor] okay alright so four days ago you started feeling badly okay now were you having chills
[patient] yeah last night i was chills and i had lot of sweating and it's really hard to swallow
[doctor] it's really hard to swallow okay now do you have pain every time you swallow or is it just periodically
[patient] every time i swallow i'm even having trouble eating i can drink okay the like really cold water feels good
[doctor] okay that's what i was gon na ask you okay so you're able to drink water and are you able to drink any other fluids have you been able to drink any you know i do n't know juices or milk shakes or anything like that
[patient] well besides my wine at night i really just drink water all day
[doctor] okay well i like to drink wine too what's your favorite type of wine
[patient] peanut grooves yes
[doctor] it's a good one i like that too i am also a pino navar fan so there you go alright well let's now do you feel sick to your stomach at all
[patient] no i have a little bit of a stuffy nose not too bad it's really just my throat but i think my tonsils are swollen too
[doctor] and your tonsils are swollen too now has anyone else sick in your household
[patient] i do have little kids that go to school so they've always got you know those little runny noses or cough but nobody is really complaining of anything
[doctor] okay alright now have you had strep throat in the past
[patient] when i was a kid i had strep throat but i have n't had anything like that as an adult
[doctor] okay alright and what do you do for work
[patient] i i work as a cashier in a supermarket
[doctor] okay alright and did you get your covid vaccine
[patient] yep i did get my covid vaccine but it really made me feel sick so i'm hoping i do n't have to get another one later this year
[doctor] okay did so you just got the two vaccines you did n't get the booster
[patient] no i did n't get the booster because i really have n't had time to feel that sick again it really knocked me down for like two days and with the little kids it's really hard
[doctor] okay alright well i saw that they did a rapid covid test when you came in here and that was negative so that's good so you do n't have covid which is which is good now let's talk a little bit about your hypertension and hypertension since i have you here did you ever buy that blood pressure cuff that i asked you to buy
[patient] yes i did i blood the blood pressure cuff and my blood pressure is like all over the place sometimes it could be like one twenty for the top number sometimes it could be one forty for the top number i i do n't really remember the bottom number though
[doctor] okay that's okay are you taking the lisinopril i think we have you on twenty milligrams a day
[patient] yep i take it every morning with my multivitamin and my vitamin d
[doctor] okay alright and are you watching your salt intake
[patient] i really like my chips with my wine
[doctor] is n't that the best we we could get along really well outside of here alright and then tell me a little bit about your diabetes now are you are you watching your blood sugars are you taking them at home
[patient] sometimes i take that all that often again that could be all over the place sometimes i get if i take it first thing in the morning it'll be like eighty or ninety but at night sometimes it could be one forty
[doctor] okay alright and i are you still taking the metformin we have you on a thousand milligrams twice a day
[patient] uh uh yes i do take it i take it with my breakfast and with my dinner
[doctor] okay alright great alright now are you are you a meds fan or a yankie's fan or god for a bit of filly's fan
[patient] nope
[doctor] no
[patient] no do n't do n't like sports
[doctor] do n't like sports just the wine
[patient] no
[doctor] okay alright well let's go ahead i wan na just do a quick physical exam now i'm gon na be calling out some of my findings and i'm gon na let you know what that means when i'm done okay so looking here first at your vital signs your vital signs look pretty good you do have a low-grade fever of about a hundred . four right now but otherwise your blood pressure is pretty good it's about one thirty two over eighty and your heart rate is eighty four now that looks pretty good so i'm just gon na go ahead and examine you so on your facial exam i'm gon na just press on your face here does this hurt
[patient] no not no it does n't bother me
[doctor] okay on facial examination the patient has no pain to palpation of the frontal or maxillary sinuses on nasal examination there is edema and erythema of the nasal turbinates bilaterally with associated clear discharge open up your mouth and say
[patient] ah
[doctor] on throat examination there is bilateral erythema and edema of the peritonsillar space with exudates present bilaterally the uvula is midline on your neck exam i do appreciate some cervical lymphadenopathy on the right hand side on your lung exam your lungs you have some coarse rhonchi at the bases that clear with cough and on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur or or rub so what does all of that mean teresa so all of that means is that yes you're showing signs of what we call an upper respiratory infection and i'm concerned that you might have some strep in the back of your throat based on the findings so let's just talk a little bit about my assessment and plan for you okay so for your first problem of your sore throat i'm gon na go ahead and have the medical assistant come in and swab you for a rapid strep test and if that's positive i wan na go ahead and place you on or prescribe amoxicillin five hundred milligrams three times a day for ten days and i'm gon na give you some lidocaine swish and swallow so that will help with some of the pain and you can take some ibuprofen as needed which will also help with the pain and some of that fever okay i do want you to go ahead and continue to to hydrate as much as possible what kind of questions do you have about that
[patient] no that sounds good i just wanted to be sure i was okay because of the little kids
[doctor] sure now for your next problem of your hypertension i wan na go ahead and order a lipid panel on you and i think i do wan na increase i do wan na increase the lisinopril to forty milligrams once a day just to get your blood pressure under better control and we'll see how you do on the forty milligrams once a day for your third problem of your diabetes let's go ahead and order a hemoglobin a1c and just to make sure that we do n't have to make any adjustments to your metformin how does that sound
[patient] sounds good
[doctor] any questions
[patient] nope that's everything
[doctor] okay bye good to see you i'll be in touch

CLINICAL NOTE

CHIEF COMPLAINT

Sore throat.

MEDICAL HISTORY

Patient reports history of hypertension and diabetes.

SOCIAL HISTORY

Patient reports working as a cashier in a supermarket. She enjoys drinking wine.

MEDICATIONS

Patient reports taking lisinopril 20 mg daily, multi-vitamin, vitamin D, and metformin 1000 mg twice daily.

REVIEW OF SYSTEMS

Constitutional: Reports fever, chills, and profuse sweating.
HENT: Reports sore throat, dysphagia, tonsil swelling, and congestion.
Gastrointestinal: Denies abdominal symptoms.

VITALS

Temperature: 100.4 degrees F.
Blood pressure: 132/80 mm Hg.
Heart rate: 84 BPM.

PHYSICAL EXAM

Head and Face
- Examination: No pain to palpation of the frontal or maxillary sinuses.

Ears, Nose, Mouth, and Throat
- Examination of Nose: Edema and erythema of the nasal turbinates noted bilaterally with associated clear discharge.
- Examination of Throat: Erythema and edema of the peritonsillar space with exudates present bilaterally. The uvula is midline.

Neck
- General Examination: No thyromegaly, but there is some cervical lymphadenopathy on the right side.

Respiratory
- Auscultation of Lungs: Coarse rhonchi at the bases that clear with cough.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.

RESULTS

Rapid COVID-19 test performed today in office is negative.

ASSESSMENT AND PLAN

1. Sore throat.
- Medical Reasoning: The patient has experienced sore throat, fever, chills, profuse sweating, and difficulty swallowing for 4 days. There is erythema and edema of the peritonsillar space with exudates present bilaterally as well as edema and erythema of her turbinates, bilaterally.
- Patient Education and Counseling: We discussed treatment options today. I have stressed the importance of hydration.
- Medical Treatment: We will perform a rapid strep test today. If she is positive for strep, I will prescribe amoxicillin 500 mg 3 times a day for 10 days. Prescription for lidocaine swish and swallow provided for pain relief. ibuprofen can also be taken for pain and fever relief.

2. Hypertension.
- Medical Reasoning: The patient states her blood pressure fluctuates often. Her blood pressure today in office was 132/80 mm Hg. - Patient Education and Counseling: We discussed treatment options including increasing her lisinopril and diet modifications.
- Medical Treatment: Lipid panel ordered. Prescription for lisinopril 40 mg once a day is also provided.

3. Diabetes.
- Medical Reasoning: The patient's blood sugar fluctuates between 80 to 90 in the morning to 140 in the evening. She is already at 1000 mg of metformin twice a day, which she does take with meals.
- Patient Education and Counseling: We discussed the importance of achieving a healthy lifestyle and what effects that can have on her diabetes.
- Medical Treatment: I have placed an order a hemoglobin A1c.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.