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Original Question
make this organized HnP note: CC HPI: pt presents today for f/u PNAwas seen last Friaday at UPMC Urgent Care for a 1 day h/o coughtactile fevercoughwheezingwas dx with BL PNA at Urgent Careplaced on Cefdinir & Zithromaxfinished Zithromax yesterdaystill has about 5 days of Cefdinirhe is using his mom’s albuterol nebulizer; last tx last nighthe has an albuterol inhalerhe is feeling a little bit better, but still coughing, wheezingtaking Ibuprofen ROS:Const: Denies chills and fever.ENMT: Denies mouth or throat symptoms.CV: Denies chest pain.Resp: Denies symptoms other than stated above.GI: Denies diarrhea, nausea and vomiting.GU: Urinary: denies dysuria and incontinence.Musculo: Denies joint pain.Skin: Denies rash.Neuro: Denies numbness/tingling.Psych: Denies depression. Current Meds: Doxycycline Hyclate 100 mg, Ibuprofen 800 mg, Albuterol Sulfate HFA 108 (90 Base) mcg/Act, Dilantin 100 mg, Lisinopril 10 mg, Topiramate 25 mg, Dexilant 60 mg, Azithromycin 250 mg, Cefdinir 300 mg, Prednisone 20 mg Allergies: Penicillin, Amoxicillin, Haldol, Vistaril, Ativan PMH:Immun/Inj. Record:90682-Flublok 18 Years And Over 00/00/0090658-Fluzone .5 (6M-17Y) 00/00/00 00/00/00J1100-Injection Dexamethasone Sodium Phosphate, 1 MG 09/12/19 09/12/1991300-Covid-19 Pfizer vaccine, mRNA, LNP-S, PF, 30 mcg/ 0.3 mL 05/27/21 05/06/2190715-Adacel/Boostrix-Tdap 04/20/11.Health Maintenance:Colonoscopy – (6/2011) BRBPR – > single ascending diverticulum, otherwise negBlood Test – (6/2011) H/H:
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