BANNER URGCARE - HIGLEY & SOUTHERN

1215 S Higley Rd
Mesa, AZ 85206-
Patient: Malek Farley-Gray
MRN: 1134575 Admit: 02/02/2022
FIN: 1947388 Discharge: 02/03/2022
DOB/Age/Sex: 6/23/19 41 years Female Attending: EARLYWINE PA,KEVIN DEAN
Visit: UC/SDC
Printed: 2/6/2022 02:18 MST Report Request: 684481364
URGENT CARE / SAME DAY CARE
Document Name: .Urgent Care/Same Day Care Note
Result Status: 7/14/2020 19:51 MST
Signed By: EARLYWINE PA,KEVIN DEAN (7/14/2020 19:52 MST)
Service Date/Time: 7/14/2020 19:51 MST
Chief Complaint
fever, body aches, chills, fatigue started 4 days ago
Patient Information
Name: REYES, LEAH SHARAI Age: 40 Years DOB: 06/23/1980 Sex:
Female
Additional Information:
No qualifying data available.
History of Present Illness
40-year-old female presents to the clinic with body aches, fever and sore throat
symptoms have been ongoing for the last 4 days.
Review of Systems
Constitutional: Fevers, chills, sweats
Eye: No recent visual problems, eye discharge/drainage
ENMT: Sore throat, nasal congestion, no ear pain
Respiratory: Cough, no shortness of breath or wheezing
Cardiovascular: No Chest pain, palpitations, edema
Gastrointestinal: No nausea, vomiting, diarrhea, abdominal pain
Neurology: Headache, no weakness
Integumentary: No rash, pruritus
Musculoskeletal: Generalized myalgias, arthralgias, no joint swelling
Physical Exam
Vitals & Measurements
T: 39.3 °C (Tympanic) HR: 80(Monitored) RR: 16 BP: 114/83 SpO2: 94%
Other Vitals
No qualifying data available.
General: Alert, well nourished, no acute distress
Eye: EOMI, normal conjunctiva
HENT: Clear rhinorrhea bilaterally, normal tympanic membranes, moist oral mucosa,
pharyngeal erythema without exudate, no sinus tenderness
Neck: Supple, non-tender, mild reactive lymphadenopathy
Lungs: Clear to auscultation without wheezes, non-labored respiration
Heart: Normal rate, regular rhythm, no murmur
Skin: Skin is warm, dry and pink, no rashes or lesions
Musculoskeletal: Normal gait, full range of motion in all major joints
Neurologic: Awake, alert, CN II-XII grossly intact
Psychiatric: Cooperative, appropriate mood and affect
Problem List/Past Medical History
Ongoing
ADHD (attention deficit hyperactivity
disorder)
Anxiety
Asthma
Bipolar
Historical
No qualifying data
Procedure/Surgical History
• Cholecystectomy
• Knee
• Tonsillectomy
Medications
ibuprofen., 800 mg, Oral, Once
Medrol Dosepak 4 mg oral tablet, 1 packet,
Oral, Once
Tylenol Cold and Flu Severe Day & Night
Allergies
amoxicillin
sulfADIAZINE
Social History
Smoking Status - 02/11/2017
Never
Alcohol
No Changes to Abuse: No change from
last review and/or documentation.
***Current Review Date: 3-9-13, 6/17/13.
Is the Patient Alone: Yes. ***Suspected
Abuse/Neglect Observation: Sexual
molestation. History of Sexual Abuse: Yes.,
06/17/2013
Employment/School
***Current Review Date: 6-9-13. Status:
Unemployed. Patient Education Level:
High school. Patient Education
Barriers/Readiness: None identified.
***Parent/Primary Caregiver Education
Barriers/Readiness: None identified.,
06/09/2013
Home/Environment
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