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Scribe Insight

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đź“„ **Patient Details Report**

Patient Name: Ms. Johnson
Age: 42 years
Appointment Type: General Consultation




**Chief Complaint Insights**

– The patient’s chief complaints are: cough, difficulty swallowing, fever, nausea, pain, sore throat, swelling in your neck.

===== Systematic Review of Symptoms (Keywords Only) =====

Constitutional Symptoms:
– fever

Respiratory Symptoms:
– cough

Gastrointestinal Symptoms:
– nausea

Mucocutaneous Symptoms:
– redness


đź“„ **Patient Past Medical History Report**
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**Past Medical History:**
————————————————–
– The patient reports: mild fever and a little bit of a cough, but mostly it’s the pain in my throat that bothers me.
– The patient reports: bronchodilators, and I was treated with Albutero, 2 puffs, every 4-6 hours as needed, inhalation, tremors and increased heart rate.


đź“„ **Medication Summary Report**

**All Medications**
– Albutero (2 puffs), every 4-6 hours as needed.
– Dextromethorphan (10 mg), every 4 hours.
– Fluids (No dosage specified), Frequency unknown.

đź“„ **Tests Ordered Report**
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**Tests Ordered**
————————————————–
✅ **rapid test for strep** – A quick swab test of the throat that detects the presence of Group A Streptococcus bacteria.
✅ **Throat lozenges** – Temporarily soothe and relieve irritation or pain in the throat.



đź“‹ **Physician’s Plan Report**
==================================================
Based on the conversation, the following plan statements were identified:

– Check your thyroid levels again to see if your medication needs adjusting. (From transcript: ‘check back in a few days to see how you’re doing’)
– Contact us immediately if symptoms worsen. (From transcript: ‘symptoms worsen—especially if the fever gets higher or swallowing becomes painful—please contact the office or seek care right away’)
– We recommend continuing your current regimen if stable. (From transcript: ‘continue to rest, stay hydrated, and keep an eye on your fever’)

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