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
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
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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