Katrina Allergy

SUBJECTIVE
HPI-ROS:

The patient is here with complaint of a stuffy nose. The patient is here with a complaint of a stuffy nose
for about 5 days with mostly clear discharge. She denies fever or chills. She reports an eyesore. She also
complains of sore throat due to post nasal drip. She occasionally takes Zyrtec when running. She noted a
little wheezing when breathing. She admits to having asthma before and uses inhaler when running.

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.

Head: No headaches, no vertigo, no injury.

Eyes: positive for eyesore and pain underneath her eyes

Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.

Nose: positive for nasal congestion with clear discharge

Mouth: positive for sore throat

Neck: No stiffness, no pain, no tenderness, no noted masses.

Chest: Positive for wheezing when coughing

Heart: No chest pains, no palpitations, no syncope, no orthopnea.

Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no

emesis, no melena.

GU: No urinary urgency, no dysuria, no change in nature of urine.

Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or

numbness.

Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.

Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.

PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.

Head: Normocephalic, no lesions.

Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no injection or
discharge, sclera non-icteric.

Ears: EACs clear, TMs normal bilaterally.

Nose: pain upon percussion on mastoid sinuses.

Throat: there is cobble stoning due to post nasal drip.

Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.

Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.

Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of
accessory muscles of respiration.

Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.

Back: Normal curvature, no tenderness.

Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.

Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal. CN 2-
12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.

ASSESSMENT

J30.1 Allergic rhinitis due to pollen

J45.990 Exercise induced bronchospasm

PLAN

1. Advised patient that she may take over-the-counter decongestants. She may take Sudafed twice a
day, every 12 hours.

2. Advised the patient to buy saline nasal rinse. Instructed that she may take Neilmed to flush out
mucus. Informed that it will help prevent infection.

3. I prescribed the patient montelukast (Singulair) 10 mg once a day tablet to help her allergies and
asthma.

4. I will refill her Albuterol handihaler 2 inhalations four times a day as needed.

5. Prescription will be sent to her preferred pharmacy, Target.

6. Instructed to report if she develops signs of infection such as fever brown or green mucus she will be
put on antibiotics.