AI Scribe for Primary Care Physicians (PCPs)
Handle diverse patient encounters with ease. Medwriter streamlines documentation for PCPs.
Medwriter AI Session
Dr: Hi Sarah, thanks for coming in. What's been bothering you the last few days?
Patient: I've had this really sore throat and a cough since Monday. And I just feel wiped out.
Dr: Okay. Any fever or body aches with that?
Patient: Yeah, I felt feverish yesterday, didn't check the temp though. And definitely achy all over.
Dr: Anyone else sick at home or work?
Patient: My coworker had similar symptoms last week.
Dr: Got it. Let me take a look at your throat and listen to your lungs.
🗣️SUBJECTIVE:
- Patient is a 32 y/o female presenting with 3-day history of sore throat, cough (non-productive), subjective fever, fatigue, and myalgias.
- Sore throat rated 7/10, worse with swallowing.
- Denies shortness of breath, chest pain, nausea, vomiting.
- Reports sick contact at work last week with similar URI symptoms.
- PMH non-contributory. No known allergies.
- Takes OCP daily.
🩺OBJECTIVE:
- Vitals: Temp 100.8F, HR 88 bpm, RR 18, BP 118/76 mmHg, O2 Sat 99% RA.
- Exam:
- General: Appears fatigued but non-toxic.
- HEENT: Pharynx erythematous with tonsillar exudates bilaterally. No significant cervical lymphadenopathy.
- Neck: Supple.
- Resp: Lungs clear to auscultation bilaterally. No wheezes or crackles.
- Point-of-Care Testing: Rapid Strep test: Negative. Rapid Flu test: Positive (Influenza A).
📋ASSESSMENT:
- 1. Influenza A (J10.1): Based on clinical presentation and positive rapid flu test.
- 2. Acute Pharyngitis (J02.9): Likely viral etiology given negative strep test, associated with influenza.
📝PLAN:
- 1. Influenza: Prescribed Oseltamivir (Tamiflu) 75mg BID x 5 days. Started within 48 hrs of symptom onset.
- 2. Symptomatic Care: Recommend rest, increased fluid intake. OTC analgesics (Acetaminophen or Ibuprofen) for fever/myalgias/sore throat. OTC cough drops/syrup PRN.
- 3. Patient Education: Discussed diagnosis, antiviral medication, importance of hydration/rest. Advised on infection control measures (hand hygiene, covering cough). Return precautions discussed (worsening SOB, high fever, inability to keep fluids down).
- 4. Work Note: Provided excuse from work for 3 days.
- 5. Follow-up: RTC if symptoms worsen or do not improve in 5-7 days.
- 99213 - E/M code appropriate for visit complexity and prescription drug management.
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