SUBJECTIVE: Here for a sore throat, (1)________ at the ears and sinuses, and redness of her eyes bilaterally. She has had no fever, chills, nausea or vomiting. She has had some greenish-yellow discharge from her sinuses and mild discomfort. She has a history of (2) ________ in the past

OBJECTIVE: General: An alert female in no acute distress. VITAL SIGNS: Blood pressure 100/60, weight 99 pounds. HEAD, EYES, EARS, NOSE AND THROAT EXAM:
(3) ________ injected, (4) ________ clear. The (5) ________ are benign. Normal (6) ________ motions. The pharynx reveals the tonsils are 3+ in size, enlarged bilaterally, with minimal

(7) ________, and no lesions or (8) ________. The tympanic membranes are clear. No sinus tenderness to palpation. NECK EXAM: Supple, no lymphadenopathy. LUNGS: Clear, with good air exchange throughout. Rare (9) ________ wheezes are noted. NEUROLOGICAL: Unremarkable. SKIN: There are fine (10) ________ raised lesions on the upper arms and forearms bilaterally, without significant erythema.

ASSESSMENT:

• Tonsillitis.


• Acute conjunctivitis, early sinusitis.


• Dermatitis of the arms, probably (11) ________.

PLAN:

• (12) ________ 250 mg t.i.d. orally.


• Robitussin p.r.n. for congestion and cough.


• Hydrocortisone 1% cream to the areas of dermatitis b.i.d. orally.


• Recheck in 2 to 3 weeks.

1. pulling
2. tonsillitis
3. Conjunctivae
4. corneas
5. fundi
6. extraocular
7. erythema
8. exudate
9. expiratory
10. punctate
11. atopic
12. Amoxicillin