DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Nausea, vomiting, and abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who presents to the emergency department with her father. Father states she has had a sore throat and has not been eating for the last two days. She has also vomited approximately 10 times today, and she has been unable to keep clear liquids down. She has had several episodes of diarrhea also. She has had abdominal pain, which is a diffuse aching sensation. She states that she is unable to see her doctor for this.
PAST MEDICAL HISTORY: Unremarkable.
ALLERGIES: None.
SOCIAL HISTORY: She occasionally smokes cigarettes.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, pulse 90, respirations 18, and O2 sat 98% on room air.
GENERAL: The patient is a well-developed (XX)-year-old in no distress.
HEENT: Moist mucous membranes. Throat is slightly erythematous posteriorly. No exudate or trismus. TMs, canals are clear.
NECK: Supple.
HEART: Regular rate and rhythm, S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: The patient’s abdomen is soft. Positive bowel sounds. Tender with palpation in the epigastrium. No lower quadrant tenderness. No rebound, no masses.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: Rapid strep screen is positive. Pregnancy test negative. Amylase and lipase normal. WBC is 14.2, hemoglobin 14. Chem-7 normal.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. She underwent workup. She was given IV fluids as well as Phenergan. She has been able to tolerate clear liquids in the emergency department. She was re-examined and was discharged in good condition with her father.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old female with strep. We will discharge her to home.
PLAN:
1. Amoxil 500 mg.
2. Phenergan 25 mg, #10.
3. Push clear liquids.
4. Follow up with her pediatrician.
5. Return if symptoms worsen.
DISPOSITION: Home.
DIAGNOSES:
1. Acute group A streptococcal pharyngitis.
2. Acute gastroenteritis.
