DOE, JOHN
January 14, 2001
SUBJECTIVE: John is a 20-year-old white male smoker
with no history of
asthma and complains of chest congestion and cough for the past two weeks.
He has been sick off and on during that time with some upper respiratory
symptoms, temperature up to 99.3, and being awake due to the cough. He has
tried Tylenol Cold and vaporizer.
He also complains of severe groin itching and describes a
rash, has jock itch,
which is worse in the summer. He has tried over-the-counter medications
without relief.
OBJECTIVE: Alert and no acute distress. ENT: TMs are
WNL. Nares are
without discharge. Oropharynx is WNL.Neck is supple with no LAN. Chest is
CTA. Cor RRR without MRG. Respirations are unlabored. Skin examination is
deferred.
ASSESSMENT/PLAN:
1) Acute bronchitis have reviewed rationale behind symptomatic relief first
and given antibiotic handout. He is given albuterol inhaler plus Robitussin
AC 4 ounces with appropriate medication warnings and direction to use
Robitussin only at night. He is to follow-up or call if no better in one week.
2) Tinea cruris by history will give Mentax cream to use b.i.d. and follow-up
p.r.n. no better.
Bill Smith, M.D.
D: 01/14/01
T: 01/15/01
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