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    Princess Arianne Macaranas Five Hello Rache Practice

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    Dianne Macaranas
    Princess Arianne Macaranas Five presented to the office with a sore throat and cough for one week. On examination, she had a swollen left tonsil and injected left ear. She was diagnosed with bronchitis. The treatment plan included an antibiotic prescription for the ear infection and a strep test to detect the presence of infection.

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    Princess Arianne Macaranas Five Hello Rache Practice

    Uploaded by

    Dianne Macaranas
    250 views2 pages
    Princess Arianne Macaranas Five presented to the office with a sore throat and cough for one week. On examination, she had a swollen left tonsil and injected left ear. She was diagnosed with bronchitis. The treatment plan included an antibiotic prescription for the ear infection and a strep test to detect the presence of infection.

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    Princess Arianne Macaranas Five presented to the office with a sore throat and cough for one week. On examination, she had a swollen left tonsil and injected left ear. She was diagnosed with bronchitis. The treatment plan included an antibiotic prescription for the ear infection and a strep test to detect the presence of infection.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    250 views2 pages

    Princess Arianne Macaranas Five Hello Rache Practice

    Uploaded by

    Dianne Macaranas
    Princess Arianne Macaranas Five presented to the office with a sore throat and cough for one week. On examination, she had a swollen left tonsil and injected left ear. She was diagnosed with bronchitis. The treatment plan included an antibiotic prescription for the ear infection and a strep test to detect the presence of infection.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    1/5/22, 7:42 AM Encounter - Office Visit Date of service: 01/05/22 Patient: Princess Arianne Macaranas Five DOB: 11/20/1998

    1/20/1998 PRN: FP926902

    PATIENT FACILITY ENCOUNTER


    Princess Arianne Macaranas Five Hello Rache Practice NOTE TYPE SOAP Note
    DOB 11/20/1998 T (520) 468-5817 SEEN BY Princess Arianne
    AGE 23 yrs 4990 E Mediterranean Drive, Macaranas
    SEX Unspecified Suite D, DATE 01/05/2022
    PRN FP926902 Sierra Vista, AZ 85635 AGE AT DOS 23 yrs
    Not signed

    Chief complaint
    Sore throat and cough

    Patient identifying details and demographics


    FIRST NAME Princess Arianne SEX Unknown RACE -
    Macaranas DATE OF BIRTH 11/20/1998 ETHNICITY -
    MIDDLE NAME - DATE OF DEATH - PREF. LANGUAGE -
    LAST NAME Five PRN FP926902 STATUS Active patient
    SSN -
    CONTACT INFORMATION
    ADDRESS LINE 1 - CONTACT BY -
    ADDRESS LINE 2 - EMAIL -
    CITY - HOME PHONE -
    STATE - MOBILE PHONE (520) 456-7891
    ZIP CODE - OFFICE PHONE -
    OFFICE EXTENSION -
    FAMILY INFORMATION
    NEXT OF KIN - PATIENT'S MOTHER'S MAIDEN -
    RELATION TO PATIENT - NAME
    PHONE -
    ADDRESS -

    Vitals for this encounter


    No vitals recorded

    Subjective
    SUBJECTIVE
    HPI-ROS:

    The patient is here for his sore throat and cough which started a week ago. He measured his temperature one time and got 103 F.
    His mucus is green in color and is remarkable in nausea. He feels hot and had a hard time sleeping.

    REVIEW OF SYSTEMS:
    General: Generally healthy, no change in strength or exercise tolerance.
    Head: No headaches, no vertigo, no injury.
    Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
    Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
    Nose: No epistaxis, no coryza, no obstruction, no discharge.
    Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
    Neck: No stiffness, no pain, no tenderness, no noted masses.
    Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
    Heart: No chest pains, no palpitations, no syncope, no orthopnea.
    Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.
    https://static.practicefusion.com/apps/ehr/index.html?utm_source=exacttarget&utm_medium=email&utm_campaign=InitialSetupWelcomeAddedUser&f… 1/2
    1/5/22, 7:42 AM Encounter - Office Visit Date of service: 01/05/22 Patient: Princess Arianne Macaranas Five DOB: 11/20/1998 PRN: FP926902

    GU: No urinary urgency, no dysuria, no change in nature of urine.


    Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness.
    Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
    Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
    PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.
    Objective
    OBJECTIVE
    General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
    Head: Normocephalic, no lesions.
    Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no injection or discharge, sclera non-icteric.
    Ears: Left ear is red and injected.
    Nose: Mucous is green
    Throat: Left tonsils is swollen
    Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
    Chest: Remarkable for ronchi and wheezes.
    Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
    Back: Normal curvature, no tenderness.
    Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
    Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal. CN 2-12 intact. No cognitive
    dysfunction. No sensory or motor deficits. Gait normal.
    Assessment

    Diagnoses attached to this encounter:


    (J40) Bronchitis, not specified as acute or chronic

    Plan
    1. The patient got an infection on his left ear, doctor advised him to take an antibiotics. The doctor prescribe a Zpak patient's
    preferred pharmacy was walgreens
    2. We will do strep test for the patient to detect the presence of the infection.

    I, Hello, MD, personally performed the services described in this documentation, as scribed by Princess Arianne P. Macaranas, RPm
    in my presence, and it is both accurate and complete.

    https://static.practicefusion.com/apps/ehr/index.html?utm_source=exacttarget&utm_medium=email&utm_campaign=InitialSetupWelcomeAddedUser&f… 2/2

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