LOCATION: Outpatient, Clinic PATIENT: Dolly Lee PRIMARY CARE PHYSICIAN: Frank Ga

Question

LOCATION: Outpatient, Clinic

PATIENT: Dolly Lee

PRIMARY CARE PHYSICIAN: Frank Gaul, M.D.

SUBJECTIVE: Dolly comes in for two concerns. First, is a recent prominent cough with a sore throat. Cough is productive at times and complains of fever and chills as well.
     The second concern is the patient is in for a recheck on depression. She has noticed no improvement of problems since starting the Zoloft, and has been on 50 mg for two weeks and 25 mg the first week.

OBJECTIVE: On exam weight is 220. Pulse is 84. R is 16. The patient, is NAD. Fundi: Benign. PERRLA, normal EOMs. TMs are benign. Pharynx is slightly erythematous. Neck is benign. No anterior or posterior nodes. Heart is S1-S2. Lungs are clear.

ASSESSMENT:
1. Acute bronchitis with probable pharyngitis.
2. Manic depressive episode.

PLAN: We will continue Dolly on the 50 mg dose and six-week samples were given. We will see her back in six weeks, and if not markedly improved we will consider switching to 100 mg dose at that time. If she should have any problems in the meantime, she will call or return to the clinic.
     I placed on her amoxicillin 500 mg t.i.d. times 10 days for pharyngitis and bronchitis symptoms. She will push fluids, and she will use Robitussin AC if need be for dry cough with appropriate precautions and follow up for this if not improving also.

Explanation / Answer

We will continue Dolly on the 50 mg dose and six-week samples were given. We will see her back in six weeks, and if not markedly improved we will consider switching to 100 mg dose at that time. If she should have any problems in the meantime, she will call or return to the clinic.
Placed on her amoxicillin 500 mg t.i.d. times 10 days for pharyngitis and bronchitis symptoms. She will push fluids, and she will use Robitussin AC if need be for dry cough with appropriate precautions and follow up for this if not improving also.TV

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