SUBJECTIVE: The patient is here today with her sister and her dad. She complains of sharp pain on the left side of her chest just underneath her breast. She states that her throat hurts on the left side. She felt ear pain for a few seconds on and off. The past two days, Monday and Tuesday, when it was very hot outdoors, she was dizzy, kind of nauseous and complained of headache. She also states that when she takes a full deep breath, it does not seem to fill up her lungs with air. She also complained of pins and needles on both of her fingers yesterday that lasted for about five hours. She did not have any fever. The pain on her left chest is not associated with any activity.
OBJECTIVE: The patient is a healthy-looking young woman. Blood pressure is 112/72. Temperature is 97.8. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose: Clear. There is no tonsillopharyngeal redness. There is no neck gland enlargement and neck is supple. Chest and Lungs: Clear. No rales. No rhonchi. No wheezing. Heart: Normal. Regular rhythm and no murmurs. Abdomen: Flat and soft, no hepatosplenomegaly.
ASSESSMENT:
1. Costochondritis.
2. Most probable dehydration, explains the dizziness and nausea and headache yesterday and the day before when the temperature was very hot outside.
PLAN: The patient was advised to make sure that she gets enough water. She will take Motrin or any ibuprofen preparation for the chest pain. She will observe whether the pins and needles in both fingers recur. We asked her to take a multivitamin.
SUBJECTIVE: The patient has been coughing intermittently for a week now. When he coughs, it is continuous. He sounds very croupy. He did not have any fever. Otherwise, he feels fine. Last night, started with stuffy nose. The patient takes albuterol p.r.n. and Flovent. For the past few days, mom has been administering both the Flovent and albuterol. He was never diagnosed as severely asthmatic.
OBJECTIVE: The patient is ambulatory. He appears well. He is not in any acute distress. Temperature is 98.4. He weighs 64 pounds. He is up and about. His cough is dry. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose is clear. Mouth is clear. There is no neck mass. Chest and Lungs: Symmetric. Good air entry and clear breath sounds. Heart: Normal. Abdomen: Benign.
ASSESSMENT: Cough for about a week, most likely viral, could be allergic in nature.
PLAN: We have reassured mom that his examination is normal. We would wait about several days. He has an appointment on Tuesday, and we think that would just be right to evaluate him. Otherwise, if he develops a fever, mom will call.
SUBJECTIVE: The patient has had sore throat, dysphagia, and halitosis for about one day. He has had congestion and coryza without cough for about one week. There has been no fever, headache, earache, chest pain, dyspnea, wheezing, stomach ache, nausea, vomiting, or diarrhea.
OBJECTIVE: Temperature is 97.4 orally. Weight is 90 pounds. In general, he looks well without significant distress. Tympanic membranes are clear bilaterally without any redness or pus. He had a slight nasal congestion with red mucosa. Oropharynx reveals red tonsils and palate without any exudate. Bilateral tender anterior cervical nodes. Lungs are clear to auscultation with good breath sounds. No rales, rhonchi, or wheezes. Cardiovascular: Regular rate and rhythm. No murmur. Abdominal exam was normal.
LABORATORY DATA: Rapid strep test was positive.
ASSESSMENT:
1. Strep pharyngitis.
2. Allergic rhinitis.
PLAN:
1. Penicillin 250 mg p.o. t.i.d. for 10 days.
2. Change his toothbrush in three days.
3. He will be contagious for 24 hours, though can go back to school in two days if he is feeling well.
4. Anyone he has been in contact with that has a sore throat should see their physician.
SUBJECTIVE: The patient was seen a few weeks ago for pneumonia, thought to be mycoplasma, and treated with azithromycin. At that time, we were not sure if the wheezing was related to the infection or perhaps early asthma, but he got better. He had a cold for a few days and started wheezing two days ago. That night, he was taken to the emergency room where he had significant wheezing but responded to a nebulizer. They sent him home with a Ventolin HFA and AeroChamber, but he was unable to do it effectively and mom switched to his cousin’s nebulizer, an albuterol solution, which was much better than that. He seems to be doing a lot better now and only has some significant congestion and occasional cough. He is otherwise well.
OBJECTIVE: Temperature is 97.4. Weight is 40 pounds. In general, he is well, happy, and active. There is no respiratory distress worsened with coughing. Tympanic membranes are normal bilaterally. He had a clear nasal discharge with red mucosa. There was no neck adenopathy. Lungs were clear to auscultation. Good breath sounds. There were no rales, rhonchi, or wheezing. Cardiovascular: Regular rate and rhythm, no murmur. Abdominal exam was normal.
ASSESSMENT:
1. Reactive airways disease, responding well to nebulized albuterol.
2. Upper respiratory tract infection.
PLAN:
1. We gave him a prescription for albuterol solution, and he is to use one ampule every four hours until we see him again.
2. We also gave them a nebulizer with tubing so that he would have his own rather than using his cousin’s.
3. Follow up in five days, at which point we will begin to taper his nebulizer if he is doing well.
SUBJECTIVE: Dad has noted a rash on the patient since Friday. She did not have any fever and no upper respiratory symptoms. Rash is raised, small and itchy. Dad has been giving her Benadryl.
OBJECTIVE: The patient is alert, awake, and not in any distress. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose: Clear. Mouth is clear, and there is no redness of the pharynx. There is no neck gland enlargement. Chest and Lungs: Clear. Heart: Normal. Abdomen: Benign. There is a rash on the trunk. These are raised, slightly erythematous papules, very fine and almost have a sandpaper feel to it. The upper extremities are also a little bit involved, but none on the lower extremities.
ASSESSMENT: Fine papular, slightly erythematous rash on the trunk. Cannot rule out the possibility of strep. Could be viral. Could be allergic in nature.
PLAN: Rapid strep test and throat culture will be done to rule out the possibility of strep. If it is negative, management will be only the use of Benadryl or Zyrtec since this is only once a day. We also gave dad a sample of Eucerin anti-itch cream.
