John Lewis 218887

12/7/2015

Student: 008902190
Patient: John Lewis: M: 5/05/1979: 12/07/2015 08:14PM

Chief complaint
The Chief Complaint is: Sinusitis follow-up.
.

Past medical/surgical history

Reported:
Medical: A recent URI.
Medications: Taking over-the-counter medications.

Personal history
Behavioral: Current smoker was 20 years.

Review of systems
Systemic: No generalized pain and not feeling tired or poorly. Fever. No chills.
Head: Headache frontal and sinus pain.
Neck: No swollen glands in the neck.
Eyes: No vision problems.
Otolaryngeal: No hearing loss, no earache, and no discharge from the ears. Nasal discharge and nasal
passage blockage. No sore throat.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: No dyspnea, no cough, not coughing up sputum, and no hemoptysis.
Gastrointestinal: Normal appetite, no nausea, no vomiting, no abdominal pain, and no diarrhea.
Genitourinary: No changes in urinary habits and no dysuria.
Musculoskeletal: No muscle aches.
Neurological: No dizziness.
Psychological: No depression and no sleep disturbances.

Physical findings
Vital Signs:

Vital Signs/Measurements

Value

Oral temperature
99.7 F
RR
17 breaths/min
PR
68 bpm
Blood pressure
120/88 mmHg
Weight
177 lbs
General Appearance:
Awake. Alert. Oriented to time, place, and person.
Head:
Injuries: No evidence of a head injury.
Neck:
Maneuvers: Neck pain was not elicited by motion.
Eyes:
General/bilateral:
Pupils: Normal.
Ears:
General/bilateral:
Hearing: No hearing abnormalities.
Nose:
General/bilateral:
Discharge: Nasal discharge seen. Purulent nasal discharge.
Cavity: Nasal septum normal. Nasal turbinate not swollen.
Sinus Tenderness: Tenderness of sinuses.
Pharynx:
Oropharynx: Tonsils showed no abnormalities.

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Normal Range
97.6 - 99.6
18 - 26
50 - 100
100-120/60-80
125 - 225

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John Lewis 218887

12/7/2015

Mucosal: Pharynx was not inflamed.

Lymph Nodes:
Normal.
Breasts:
General/bilateral:
No breast mass was found. No tenderness of the breast.
Lungs:
Respiration rhythm and depth was normal. Respiratory movements were normal. Chest was normal
to percussion. No wheezing was heard. No rhonchi were heard. No rales/crackles were heard.
Cardiovascular:
Heart Rate And Rhythm: Normal.
Murmurs: No murmurs were heard.
Abdomen:
Palpation: No abdominal tenderness. No mass was palpated in the abdomen.
Hernia: No hernia was discovered.
Neurological:
Cognitive functioning was normal.
Speech: Normal.
Balance: Normal.
Reflexes: Normal.

Assessment
Acute sinusitis
Allergies
No allergies.

Plan
Fluids
Amoxicillin

500 mg cap (1 po q8h 10) DISP:30 Refill:1 Generic:Y Using:Amoxil Mfg: SmithKline Beecham

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