Clinical note · #25
Office & outpatient
Patient Name: Romi Baer
Age: 39 years
Date of Service: 09/15/2025
Place of Service: Office – Outpatient
Provider: Internal Medicine
Chief Complaint: Sore throat and nasal congestion for 3 days.
History of Present Illness (HPI):
The patient returns to the office today for evaluation of sore throat and nasal congestion that began approximately three days ago. He was last seen in this clinic earlier this year for routine care, and his prior records were reviewed. Symptoms developed gradually and have remained stable. He reports mild throat discomfort, particularly with swallowing, and nasal congestion. He denies fever, chills, cough, shortness of breath, chest pain, nausea, vomiting, rash, or recent emergency room visits. He has tried throat lozenges with partial relief. No known sick contacts.
Review of Systems (ROS):
- Constitutional: Denies fever or chills
- ENT: Positive for sore throat and nasal congestion
- Respiratory: Denies cough or shortness of breath
- Cardiovascular: Denies chest pain or palpitations
- Gastrointestinal: Denies nausea, vomiting, or abdominal pain
- All other systems reviewed and negative
Past Medical History (PMH):
- No chronic medical conditions reported
Medications:
- None
Allergies:
- No known drug allergies
Physical Examination:
- Vital Signs: BP 118/74 mmHg, HR 76 bpm, RR 16/min, Temp 98.2°F, SpO₂ 98% RA
- General: Alert, oriented, no acute distress
- HEENT: Mild erythema of posterior pharynx without exudates; nasal mucosa mildly congested; tympanic membranes clear
- Neck: No cervical lymphadenopathy
- Lungs: Clear to auscultation bilaterally
- Heart: Regular rate and rhythm, no murmurs
- Skin: No rash noted
Assessment:
- Acute pharyngitis
- Upper respiratory symptoms
Plan:
- Symptoms discussed and findings reviewed with the patient
- No antibiotics indicated at this time based on clinical presentation
- Supportive care recommended including hydration, warm saline gargles, and acetaminophen 500 mg orally every 6 hours as needed for throat pain or discomfort, not to exceed 3,000 mg per day
- Patient advised to monitor symptoms and return if symptoms worsen, persist beyond 7–10 days, or if fever or new symptoms develop
- Patient verbalized understanding and agreement with the plan
Patient Education / Counseling:
Discussed expected course of illness, warning signs, and appropriate use of over-the-counter medications.