GenitourinaryDid not assess. MusculoskeletalFull ROM seen in all 4 extremities.Neurological Alert and oriented to person, place and time. No gross focal, motor or sensory deficit. Balance stable and normal gait.PsychiatricPatient pleasant, dressed in jeans and shirt. Maintains eye contact. Answers questions appropriately.Lab TestsRapid Strep - NegativeThroat Culture - Pending
Special TestsNoneDiagnosis Differential Diagnoseso1- Acute sinusitis (J01.90)o2- Otitis media (382)o3- URI (465.9)DiagnosisPrimary Acute sinusitis (J01.90)Secondary Cerum impaction right ear (H61.21)Plan/TherapeuticsoPlan: Further testing: NoneMedicationAmoxicillin 500 mg disp #21. 1 tablet PO TID x 7 days.Debrox drops. 5 drops to right ear BID x 7 days.Tylenol 500 mg every 6 hours PRN pain/feverIbuprofen 400 mg every 6 hours PRN pain/feverEducationContinue using OTC Tylenol/ibuprofen to manage pain/fever. Limit Tylenol to less than 4 g per day. Instruct to take antibiotic with food to present upset stomach.Increase fluids, use nasal saline spray PRN.
Follow up with PMD if any worsening or unresolved symptoms continue.Non-medication treatmentsNoneEvaluation of patient encounter
- Fall '17
- Dry cough, nasal congestion, Sinusitis, Omnaris nasal spray, yellow nasal discharge