DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Cough, whole body aches, and fever.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American woman with a history of hypercholesterolemia. The patient presented to the emergency room complaining of a three-day history of cough productive of little clear and green phlegm, headache, whole body aches, sore throat, and pleuritic chest pain. No nausea, vomiting, or diarrhea. No ear pain, no joint pain, swelling, or skin rash.
PAST MEDICAL HISTORY: Hypercholesterolemia.
PAST SURGICAL HISTORY: None.
GYNECOLOGIC HISTORY: The patient is gravida 3, para 2. Last menstrual period was MM/DD/YYYY.
ALLERGIES: None.
MEDICATIONS: Simvastatin, vitamin D, and Robitussin nasal spray.
SOCIAL HISTORY: The patient is married and lives with her husband and children. She denies tobacco or drug use. She drinks alcohol.
FAMILY HISTORY: Father has hypertension. Mother has diabetes mellitus type 2. No reported family history of cancer or coronary artery disease.
REVIEW OF SYSTEMS: As above and is otherwise unremarkable.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed, well-nourished African-American woman, sitting up on a gurney, pleasant, cooperative, in no acute distress.
VITAL SIGNS: Blood pressure 110/78, heart rate 108, respiratory rate 20, temperature 99.6, and oxygen saturation 99% on room air.
HEENT: Head is normocephalic and atraumatic. Eyes: Conjunctivae are pink. Mouth: Mucous membranes are moist. Posterior oropharynx shows some mild erythema. No edema. No exudate. Ears are within normal limits. Normal landmarks. Auditory canals within normal limits.
NECK: Supple. No adenopathy.
HEART: Tachycardic. No murmur.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: No cyanosis, clubbing, or edema.
CLINICAL IMPRESSION: Upper respiratory infection.
PLAN:
1. Disposition to home in stable condition.
2. Prescription for Tamiflu 75 mg, #10.
3. Tessalon Perles.
4. Z-Pak.
5. We have advised her to continue ibuprofen or Tylenol as needed for pain and fever.
6. Follow up with her primary doctor.
7. Rest and drink plenty of fluids.
8. Return to the emergency room if there is any worsening of her symptoms.
9. We have given her a work release form for three days.
She and her husband expressed understanding and agreement with the above plan.
CONDITION: Stable.
DISPOSITION: Discharged.
