SUBJECTIVE: This is a (XX)-year-old Hispanic male with medical history significant for high blood pressure, who comes in with nasal congestion, cough, sore throat, feeling weak, having a little bit of abdominal discomfort with loose stools for the last three to four days. The patient indicates that the whole family was sick with similar symptoms. He has subjective fevers, chills, nausea, but no vomiting and he has lost appetite and is feeling weak with generalized aches and pains. His cough is mostly nonproductive. He has no chest pain and no shortness of breath.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Right knee surgery x3. He has also had kidney stone removed.
CURRENT MEDICATIONS: HCTZ 25 mg daily.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: The patient smokes one pack per day for the last several years and drinks a couple of beers per week.
REVIEW OF SYSTEMS: Essentially as in the HPI.
OBJECTIVE:
VITAL SIGNS: Blood pressure 126/82, pulse 100, temperature 99.4, respiratory rate is 18. Pain is 7/10. Saturation is 97% on room air.
GENERAL: The patient is looking unwell, but in no acute distress.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, reactive to light, and accommodation. Extraocular movements are intact. There is no icterus, cyanosis, or pallor of the conjunctivae. Tympanic membranes are dull, but not inflamed bilaterally. Nasal turbinates are congested with clear exudates. Sinuses are uncomfortable to percussion. Posterior pharynx is minimally erythematous. No exudates are noted.
CHEST: Air entry is adequate bilaterally with occasional scattered rhonchi. No crackles are appreciated.
HEART: Sounds 1 and 2 are heard and are normal. Regular rate and rhythm, somewhat tachycardic, but no murmurs, gallops, or rubs.
ABDOMEN: Soft and nontender. Bowel sounds are present but somewhat hyperactive. There is no hepatosplenomegaly.
SKIN: Without rash.
EXTREMITIES: Without edema, cyanosis, or clubbing.
ASSESSMENT: Influenza.
PLAN:
1. The patient will be put on Phenergan with Codeine 5 mL p.o. t.i.d. for 7 days.
2. Zyrtec 10 mg p.o. daily for 10 to 14 days.
3. He is instructed to take Tylenol p.r.n. for aches and pains, to drink a lot of liquids and to stay home and rest.
4. He has been given a note for return to work.
5. If he does not get any better, he will come back through urgent care for evaluation.
