James, Christyne               dob 07/01/1959             43 & 7/12 y/o                  2-26-03

000-0000                            000-0000  


Problem #1:   

S: 5 d dysuria and frequency w/o flank pain, nausea, vomiting, fever,chills, vaginal dc nor abd pain

O: NAD nontoxic CVA nontender

A: cystitis 595.9  

P:   bactrim DS 1 bid #2

rto or call if not better


Problem #2:   

S: 7 d paranasal sinus pressure w/ nasal congestion and postnasal discharge w/o nausea, vomiting, fever, or chills nor sob nor chest pain;

O:   sinus percussion tenderness; otherwise conjunctivae not grossly injected; TM's wnl; oropharynx wnl; neck wnl; nasal membranes wnl

A:  acute sinusitis 461.9

P:  see med above


Problem #3:   

S: 2 weeks R posterolateral neck neck ache since MVA; no LOC nor head trauma

O: moderate LOM neck, focal tenderness affected muscles

A: cervical whiplash 847.0

P: soma 350 mg qid prn #40; darvocet N 100 1 q 4-6 hr prn pain #30; rest, heat; rto or call if not better; slip for PT given


John Smith, MD        

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