CC
Lilly is a 24-year-old female here today with a young child, to discuss not feeling well.
HPI
The patient tells me she was worried she may have strep throat, but now she is not sure that is what she has. Her symptoms started on Sunday June 14th, where she felt very tired most of the day. She also had a sore throat. Those symptoms have persisted. She now has a cough and some feeling of chest congestion. She has had a stuffy nose, and a runny nose and she is having some pressure in her face and head. She has had a good appetite. There has been no vomiting or diarrhea. She does not have asthma. She has been a lifetime nonsmoker. She has not had any recent travel outside of the country. No visible rashes. She was concerned about strep because of her sore throat, but fatigue seems to be a predominant symptom. She has not taken any medication for her symptoms thus far.
Medications
Biotin supplement, vitamin D, Differin cream and doxycycline.
O
Vital Signs
Temperature: 98.1. BP: 122/70. HR: 80. R: 14. W: 265.
General
A well-developed, well-nourished female in no acute distress seated comfortably in the exam room. …show more content…
We discussed the differential diagnosis. She was thinking it might be more related to allergies, though I am suspicious there might be something more viral going on. I will send her strep test for a culture and I will review those results with her when they become available. We also drew a CBC with differential and a Monospot here today in the office. She will practice good hand hygiene to avoid new illness or spread to others. She is aware of what signs and symptoms to be monitoring for. She will call me she has not heard the results of her testing within a couple of days. She does voice understanding of these recommendations. All questions were answered in the office
Lilly is a 24-year-old female here today with a young child, to discuss not feeling well.
HPI
The patient tells me she was worried she may have strep throat, but now she is not sure that is what she has. Her symptoms started on Sunday June 14th, where she felt very tired most of the day. She also had a sore throat. Those symptoms have persisted. She now has a cough and some feeling of chest congestion. She has had a stuffy nose, and a runny nose and she is having some pressure in her face and head. She has had a good appetite. There has been no vomiting or diarrhea. She does not have asthma. She has been a lifetime nonsmoker. She has not had any recent travel outside of the country. No visible rashes. She was concerned about strep because of her sore throat, but fatigue seems to be a predominant symptom. She has not taken any medication for her symptoms thus far.
Medications
Biotin supplement, vitamin D, Differin cream and doxycycline.
O
Vital Signs
Temperature: 98.1. BP: 122/70. HR: 80. R: 14. W: 265.
General
A well-developed, well-nourished female in no acute distress seated comfortably in the exam room. …show more content…
We discussed the differential diagnosis. She was thinking it might be more related to allergies, though I am suspicious there might be something more viral going on. I will send her strep test for a culture and I will review those results with her when they become available. We also drew a CBC with differential and a Monospot here today in the office. She will practice good hand hygiene to avoid new illness or spread to others. She is aware of what signs and symptoms to be monitoring for. She will call me she has not heard the results of her testing within a couple of days. She does voice understanding of these recommendations. All questions were answered in the office