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Original Question
What is the review of system in bullet format head to toe. Initials AN, Age 17, Sex F, Race Asian American S. CC “For the last 6 days I have been having a headache, sore throat and feeling tired I’m here to get a school letter”. HPI: AN mentioned that shes been dealing with a headache, along with cough and sneezing for the 6 days now. She described her headache as moderate. Mentioned feeling quite exhausted. AN said she hasn’t experienced any vomiting episodes and hasn’t had any fevers during this period. She also noted that she hasn’t been around anyone who’s sick recently that could have led to her illness. AN and her mother both mentioned that she has a history of migraines and often uses Tylenol for relief, from them regularly. She mentioned feeling a bit dizzy. Said she had no trouble swallowing. Her mother gave her Aquanza to help ease her congestion. Location: head, throat Onset: 6 days ago Character: pressure mid headache. Associated signs and symptoms: Headache • Cough • Sneezing • Feelings of extreme tiredness • Mild dizziness Timing: After school on Monday Exacerbating/relieving factors: Running nose and coughing, Aquanaz relieves the coughing and running nose. Denies pain 0/10 Current Medications: Acetaminophen 325 mg pain reliever dosage 650 mg every 6 hours for pain/fever as needed. OTC Aquanaz to relieve congestion Allergies: NKDA PMHx: Migraines, Arthritis, Urticaria, Insomnia, dysmenorrhea, mood disturbances, constipation, epigastric pain, Acne vulgari
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