PROGRESS NOTE

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

PATIENT: JULIE ANN KENNEDY

DATE OF BIRTH: 02/02/1977
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

HISTORY OF PRESENT ILLNESS: Postnasal drainage typical symptoms for her of

upper respiratory infection. She has thick yellow nasal drainage. Left ear stinging type
discomfort, started feeling bad on Saturday. She had some family members that were
positive for COVID, but she did not really have close contact with them. No fever. She
was nauseated yesterday. She took some lemon-ginger lozenges called Gin-Gins, which
did help. She does not feel like she needs anything else for nausea now. She has frontal
sinus pressure and a slight sore throat. She did have some nasal bleeding two days ago
when she blew her nose.

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

PATIENT: JULIE ANN KENNEDY

DATE OF BIRTH: 02/02/1977
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

HEENT: Head normocephalic. Conjunctiva, sclera, and lids

unremarkable.

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. Sinusitis
2. Otalgia, left ear
3. Scalp cyst
 

PLAN: Amoxil given. Discussed medication administration, side effects, and risks.
Discontinue any rash or itching. Recommend yogurt to prevent these. Recommend
Mucinex over-the-counter. She will follow up about her scalp cyst. She has not scheduled
appointment due to pandemic. Call if any problems.

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

DICTATED AND CONFIRMED.

SD/is/kk

99213-95

J32.9, h92.02, L72.9