DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Reflux.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with complaints of consistent and persistent sinus infections. The patient was actually treated this year for approximately one month by ENT with antibiotics and again back a few months ago. According to the patient, she came to the emergency department with same symptoms. At that time, during the hospital stay, it was noted that the patient was positive for Strep A and also noted leukocytosis. She thinks she was given antibiotics in the ED but does not remember going home with any antibiotics at that time. According to the patient, on Friday, she started complaining of fever of 101 and 102, restless and agitated with arthralgias, myalgias, vomiting with abdominal pain. She noticed increasing sour taste, complaining of acid. She also complains of headaches. She has had no diarrhea. She has no melena or any hematochezia. The patient has been fasting this month, so p.o. intake has been changed during this time. At the time of consultation, the patient’s biggest complaints are of arthralgias and myalgias all over and complaints of a sore throat.
PAST MEDICAL HISTORY: Chronic sinusitis infections, GERD with EGD a year ago, history of mitral valve prolapse, and palpitations.
PAST SURGICAL HISTORY: EGD, tonsillectomy, and hip surgery as a child.
ALLERGIES: None.
MEDICATIONS: Avelox, Medrol Dosepak, Rocephin, and Protonix.
SOCIAL HISTORY: The patient is divorced. She denies any alcohol intake or tobacco use.
FAMILY HISTORY: Father is in good health. Mother deceased at 75 secondary to bone cancer.
REVIEW OF SYSTEMS: A 12-point review of systems was completed and incorporated in H&P, otherwise unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Height is 5 feet 3 inches and weight is 120 pounds. Blood pressure 98/66, pulse 78, and respirations 18. The patient is afebrile.
GENERAL: She is alert and oriented.
CHEST: Essentially clear and bilaterally expanding. Respirations are even and unlabored.
HEART: S1 and S2. No rubs, murmurs, or gallops. Rhythm is regular.
ABDOMEN: Soft, slightly tender in the mid abdomen. Bowel sounds are noted throughout.
EXTREMITIES: The patient moves all extremities well and equal.
SKIN: Warm, dry, and pale pink.
LABORATORY DATA: UA is negative. White count 15.2, hemoglobin 12.2 and hematocrit 36.2, and platelet count 148,000, neutrophils 80. Sodium 134, potassium 3.4, chloride 102, CO2 of 25, BUN 8, creatinine 0.6, calcium 8.8, total protein 7.4, albumin 4.2, total bilirubin 0.3, alkaline phosphatase 58, and ALT 34, AST 38. Assay was Strep positive back six months ago. At that time, the patient’s hemoglobin was 12.8 and hematocrit was 37.8 with a white count of 16.2.
IMPRESSION:
1. History of gastroesophageal reflux disease.
2. Sore throat, concerns whether this is repeat Strep versus reflux.
3. Fevers.
4. Abdominal pain.
5. Recurrent sinusitis.
6. Strep throat.
PLAN: At this time, awaiting CT of the abdomen, pelvis, and sinuses. Infectious Disease is following the patient at this time. Also, PPI therapy increased to b.i.d. of Protonix. The patient may require EGD if continued problems with nausea and vomiting. At this time, we feel that the patient’s sore throat is due to her pharyngitis. Further recommendations pending ID evaluation and patient’s progress.
