Identifying data: L.B. 24 years old Hispanic female
Chief complaints: sore throat
HPI: Patient presents with a complaint of throat pain and pain with swallowing with onset of 2 days ago. Patient also complains of ear pain a right sided headache. Patient states she received a prescription for Azithromycin and Medrol dose pack one day ago but did not obtain prescription yet. Patient states the pain has worsened in the past 2 days. Patient denies fevers, shortness of breath, cough and muscle pain.
ROS:
Constitutional: denies chills, fatigue, diaphoresis, fever, headache, lightheadedness and weight loss.
Respiratory: positive for seasonal allergies; denies chest pain, cough, shortness of breath, hemoptysis and dyspnea
Cardiovascular: positive
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Patient instructed to notify office for any signs and symptoms of adverse reaction. Patient also instructed to not take Azithromycin and to start Medrol dose pack as prescribed. Patient instructed to take full course of antibiotics even if symptoms improve to prevent reoccurrence of symptoms.
Patient instructed to be aware of any signs and symptoms of worsening infection such as fever, ear drainage, muscle aches, coughing with sputum, wheezing, shortness of breath, difficulty in breathing, and feeling of throat closing and is to contact office immediately. If unable to reach office, go to the nearest emergency room.
Patient also instructed to increase fluid intake to 10 to 12 glasses a day, drink got tea, soup, and or use throat lozenges soothe your throat. Patient should use disposable tissues if sneezing. Patient should avoid smoking and secondhand smoke. Patient eat foods such as ice cream, Jell-o, pudding, and soup until pain with swallowing subsides (Cash & Glass,