PROGRESS NOTE

PROVIDER NAME: SYDNEY DOWELL, A.P.R.N.

PATIENT: AMANDA L. PENICK

DATE OF BIRTH: 03/13/1979
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

HISTORY OF PRESENT ILLNESS: Upper respiratory infection for three days. Feels
like she normally does when she has upper respiratory. Nasal congestion, Ears hurt.
Throat, dry yellow nasal drainage. No fever. No chills. No loss of taste or smell. No
known COVID exposure. She has been taking elderberry supplement and recently started
on a multivitamin. She does well with Amoxil.

MEDICAL (GENERAL) HISTORY

ALLERGIES: Reviewed.
PAST MEDICAL HISTORY: Reviewed.
IMMUNIZATIONS: Reviewed.
SOCIAL HISTORY: Reviewed.
FAMILY HISTORY: Reviewed.

REVIEW OF SYSTEMS:

GENERAL: No fever, chills.

CARDIOVASCULAR: No chest pain.

RESPIRATORY: No difficulty breathing.

GI: No abdominal pain, nausea, vomiting.

GU: No difficulty urinating.

INTEGUMENTARY: No rash.

PSYCHIATRIC: No depression.

PHYSICAL EXAMINATION:

VITAL SIGNS: ______

GENERAL APPEARANCE: Well developed, well nourished, and cooperative.

No acute distress.

HEENT: Head normocephalic. Conjunctiva, sclera, and lids

unremarkable.
PROVIDER NAME: SYDNEY DOWELL, A.P.R.N. Page 2

PATIENT: AMANDA L. PENICK

DATE OF BIRTH: 03/13/1979
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

CARDIOVASCULAR: Heart regular, rate and rhythm. Normal S1 and S2,

No edema.

RESPIRATORY: Respiratory effort unremarkable. Respiratory rate

and pattern normal. Lungs clear to auscultation.

MUSCULOSKELETAL: Normal gait.

INTEGUMENTARY: Skin warm and dry.

PSYCHIATRIC: Alert and oriented to person, place, time, mood, and

affect appropriate for situation. Judgment and
insight normal. Normal attention and concentration.

ASSESSMENT:
1. URI (upper respiratory infection)
2. Seasonal allergies
3. Methadone maintenance therapy patient
 

PLAN: Offered COVID testing, she declined. Amoxil given. Discussed medication
administration, side effects, and risks. Discontinue for any rash or itching. Recommended
yogurt to prevent yeast. Recommended flu vaccine. Call in two to three days if not
improved, sooner any new or worsening symptoms. Records reports flu shot done a few
days ago, but she says that was done last year, I will recommend flu vaccine.

PROVIDER NAME: SYDNEY DOWELL, A.P.R.N.

DICTATED AND CONFIRMED.

SD/is/kk

99213-95

J06.9, j30.2, f11.20