SUBJECTIVE: A 12-year-old female who has had 3 to 4 days of a (1) ________ cough. She did have a temperature to 101; this has subsequently resolved. She has had a headache and body aches. She has had no nausea, vomiting, or diarrhea. She denies any sore throat. She has general malaise. Her (2) _________ intake has been adequate.
OBJECTIVE: General: The patient appears tired, with a (3) ________ cough which is nonproductive. HEENT: TMs and (4) ________ normal. Larynx clear. Oropharynx injected. Lymphoid studding. Mucous membranes are moist without lesion. Anterior cervical adenopathy bilaterally. (5) ________: Regular rate and rhythm without murmur. Lungs are clear to (6) ________ bilaterally.
ASSESSMENT/PLAN: Upper respiratory infection of most likely viral in (7) ________. However, patients mother has a bronchitis, and her father was recently treated for an upper respiratory infection as well. Patient was given samples of (8) ________ 5-day course to take if her symptoms persist for more than 7 to 10 days. Patient is to use Robitussin-DM, ensure adequate p.o. fluid intake, and rest as possible.
Question 2
CHEST: (1) ________ and Lateral
Comparison is made with films from last month. There is relatively dense (2) ________within the right lung base. This now obscures the right (3) ________. There is also a small right pleural (4) _______which has increased in size slightly since the previous exam. The left lung is clear. The heart size is difficult to access, as the right heart border is obscured. The heart size is stable and probably normal.
OPINION: Right lower lobe (5) ________ and pleural effusion, both of which appear to have increased slightly since the previous exam.
The report was telephoned to Dr. Doe's office.
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