DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Caucasian woman with history of hypothyroidism, depression, insomnia, and anxiety. She presents to the emergency room complaining of an approximately seven-day history of cough productive of yellow phlegm, itch in her right ear, and nasal congestion. She also complains of back and chest pain with cough and with deep inspiration over the past couple of days. No nausea, vomiting or diarrhea. No dysuria. No hematuria. She has taken nothing for pain or for her symptoms at all. She denies headache, lightheadedness, or dizziness.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Depression.
3. Insomnia.
4. Anxiety.
PAST SURGICAL HISTORY:
1. C-section.
2. Carpal tunnel release.
3. Cholecystectomy.
4. Tubal ligation.
5. Tonsillectomy.
6. Endometrial ablation.
GYNECOLOGIC HISTORY: Last menstrual period was MM/DD/YYYY. She is gravida 1, para 1.
SOCIAL HISTORY: The patient is married and lives with her husband. She denies tobacco, alcohol, or drug use.
ALLERGIES: NKDA.
MEDICATIONS: Levothyroxine, amitriptyline, and Lexapro.
REVIEW OF SYSTEMS: As above and is otherwise unremarkable.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed, well-nourished obese Caucasian woman sitting up in a gurney. She is pleasant and cooperative and in no acute distress.
VITAL SIGNS: Blood pressure 130/82, heart rate 84, respiratory rate 20, temperature 100.4, and oxygen saturation 98% on room air.
HEENT: Head is normocephalic and atraumatic. Eyes: Conjunctivae are pink. Mouth: Mucous membranes are moist. There is no posterior oropharyngeal erythema, edema or exudate. Ear canals are within normal limits. Normal landmarks.
NECK: Supple. There is no adenopathy. She does have bilateral edema and erythema of the nasal mucosa.
HEART: Regular rate and rhythm. Normal S1 and S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, and nondistended with active bowel sounds.
EXTREMITIES: No cyanosis, clubbing, or edema.
DIAGNOSTIC DATA: X-ray: Chest x-ray to our reading shows clear lung fields and no bony abnormalities.
LABORATORY DATA: Influenza A and B smear positive for influenza A protein antigen. Urinalysis shows negative leukocyte esterase, negative nitrites, 60 ketones, negative blood, rare bacteria, and 1 white cell.
EMERGENCY DEPARTMENT COURSE: The patient was treated with Tylenol.
CLINICAL IMPRESSION:
1. Viral upper respiratory infection.
2. Influenza.
PLAN:
1. Disposition to home in stable condition.
2. Prescription for Claritin 10 mg, #30.
3. Tamiflu 75 mg, #10.
4. Tylenol 500 mg, #30.
5. Advised her to follow up with her primary provider or return to the emergency room if there is any worsening of her symptoms.
6. Advised her to rest and drink plenty of fluids.
She expressed understanding and agreement with the above plan.
