Presenting Complaint

Sore throat for one week
Worsened over last 24 hours
Feeling feverish

History of Presenting Complaint

Sore throat ongoing for one week with worsening over the last 24 hours
Patient has had tonsils removed previously
Feeling feverish but no recorded temperature at home
Infrequent dry cough
No shortness of breath
No wheezing
No vomiting
Able to drink fluids
No dizziness
No headaches
No fainting episodes

Observations

Temperature 37.2
Respiratory rate 18
Oxygen saturations 98%
Heart rate 70
Blood pressure 112/76

On Examination

Patient able to speak in full sentences
Throat appears very red with some exudates at the back
Central uvula
Tongue normal
No cervical lymphadenopathy
No rash
No photophobia
No neck stiffness
Chest clear on auscultation
Heart sounds normal

Plan

Antibiotics prescribed
Advised to keep well hydrated
Advised to take paracetamol for symptom relief
Follow up with general practitioner in 48 hours

Safety Netting

Advised to contact general practitioner if symptoms worsen or deteriorate
Advised to call 999 in case of emergency

Transcript[00:00] S1: Patient complaining of sore throat over the last week, worsened over the last 24 hours has had tonsils removed. Feel feverish. No recorded temperature, ongoing. Infrequent cough, dry. No shortness of breath, no wheezing, no vomiting. Able to drink fluids. No dizziness, no headaches, no fainting episodes. Um, on examination. Patient able to speak normal. Full sentences. Temperature 37.2. Respiratory rate 18. Oxygen 98. Heart rate 70. Blood pressure 112 over 76. Throat appears very red with some exudates at the back. Um. Central uvula. Tongue normal. No neck. Lymph nodes. No rash. No sign of photophobia. No neck stiffness. Chest clear. Heart. Sounds normal. Um. Prescribe antibiotics. Advised to keep hydrated. Take paracetamol. Advised to follow up with GP in 48 hours. Safety net advise if deteriorates. Worsening symptoms to contact GP. 1111999 if emergency.
[Edit] for observations, can everything be written as

temp
RR
O2
HR
BP x/x