Elizabeth

Blair Archibald
Clinical 4/4/17
Urgent Care

40-year-old female. Present for sore throat, sinus pain, ear ache, cough, congestion. Elevated
BP 177/101. Patient states that she has a history of elevated BP, but is not on medication. She
is not on any prescription medications. She is not a fall risk, and is a full code. Back of throat
red, sinuses tender to palpation, LNs mildly enlarged. Strep swab obtained, pending results.
Patient discharged with Amoxicillin 500 MG PO TID #30, Proneth-C 8 MG 10 CC PO TID PRN for
cough, Zyrtec 10 MG PO QHS #20.

71-year-old female. Present for cut to left index finger. Patient fell and sustained mild
laceration to finger, and no other injuries. Pain scale 4/10. She is not a fall risk, and is a full
code. Patient states that she has had a cervical cancer, and a hysterectomy. Patient takes
Aleve and Estrogen at home. Radiographs of left finger did not show a fracture. Finger is
bruise. Nurse soaked finger in dilute betadine, and physicians assistant explored for foreign
body. Patient discharged with instructions to soak finger at home, and perform PRICE (protect,
rest, ice, compress, elevate).

10-year-old male. Present for headache, sore throat, fever, and runny nose. Back of throat is
erythemic, and tonsils are enlarged with multiple tonsils stones. Patient is febrile today with a
temperature of 100.8 F. All other vitals WNL. He is not a fall risk, and is a full code. Step swab
obtained, pending results. Patient sent home with instructions to rest, and drink plenty of
fluids. RX- Z-Pack.

47-year-old male. Present for acute pain to right distal foot. Patient states pain 10/10. He is not
a fall risk, and is a full code. BP extremely high= 202/133. Patient states that he has a history of
elevated BP, he used to be on medications, but is no longer on medications R/T lapse in primary
care coverage. Patient is also overweight at 315 #. Exam for right foot shows minimal swelling,
and multiple small contusions present. Patient has athletes foot. Radiographs, CBC, complete
chemistry, uric acid, sedimentation rate, fungal culture. CBC comes back with elevated NEU,
chemistry= elevated GLU, uric acid WNL, sedimentation rate mildly elevated, fungal culture
pending, and radiographs show a probable non-dislocated fracture to right distal phalanges.
Patient sent with a boot and medications with orders to PRICE right foot. Administered Tetanus
vaccine to left deltoid. RX- Keflex 500 MG PO QID #40, Indocin 50 MG PO TID #30, Norco 5/325
MG PO Q6-8H.

18-year-old male. Present for right hand pain. Crab pot fell on hand. He is not a fall risk, and is
a full code. Hand mostly painful in thumb. No other history of illness or injury. Patient is not
on any medications at home. Radiographs do not show any breaks. Administered tetanus
vaccine to left shoulder, and applied brace to right hand. RX- Keflex and Motrin (unable to find
chart for dosages at the end of the day).

26 year-old-male. Present for falling 2 days ago into dresser. Sustained mild abrasion to right
side thoracic cage. He is not a fall risk today, and is a full code. Complaining of tenderness, and
pain when coughing; 6/10. Lungs CTA, palpation only tender, no painful. Patient has an allergy
to Ridalin. Abrasion cleaned, and bandage applied. Tetanus shot administered to left deltoid.
RX- Motrin 800 MG PO TID #30, Norco 5/325 MG PO QHS #15.