Patient Information:
- 8-year-old female patient
- History of tonsillitis
Reason for Visit:
- Fever
- Tiredness
- Difficulty swallowing
Vital Signs:
- Blood Pressure: 116/72
- Pulse: 81
- Temperature: 101.3°F
Examination Results:
- Enlarged tonsils
- Swollen lymph nodes
Tests Ordered:
- Complete Blood Count (CBC)
- X-ray
Diagnosis:
- Chronic tonsillitis
Primary Care Provider (PCP):
- Prescriptions dispensed:
- Ibuprofen (250 mg per 5 ml): 1 teaspoon to be taken twice a day as needed for pain
- Biaxin (250 mg per 5 ml): 1 teaspoon every 12 hours for 7 days
Follow-Up:
- Return in 7 days to schedule a tonsillectomy (surgical removal of tonsils).