ASSESSMENT & PLAN · BY PROBLEM
1. Acute pharyngitis (J02.9)
Three days of sore throat, no cough, tender anterior cervical nodes, temp 100.6 °F. Rapid strep positive. Amoxicillin 500 mg BID for 10 days.
2. Type 2 diabetes without complications (E11.9)
Due for review. HbA1c 8.1% on labs drawn last month, not yet discussed. Metformin 1 g BID continued; referred to the practice diabetes nurse.
3. Immunization status
Influenza vaccine declined last fall, accepted today. Administered in clinic; lot number recorded in the clinic's vaccine field.
ICD-10 J02.9 · E11.9Protocol: Adult preventive care v3 · flu vaccine flagged