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Note: Patient should provide information only if asked by the intern pharmacist.

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Name

Judy Hunter-Johnson

Age

55 years old

Symptoms and History of Present Illness (HPI)

About a week ago I was drinking water from a park fountain and subsequently developed some intermittent nausea/vomiting. Lately, I’ve been experiencing shortness of breath, fevers (although I haven’t actually taken my temperature), chills, right-sided chest pain, and a cough with rusty-brown colored phlegm. After a few days of not feeling well, I went to an urgent care clinic and received a prescription for Augmentin, which I took for 2 days. I have also been taking acetaminophen and Mucinex DM, but I feel my symptoms are getting much worse. I barely slept last night with all this coughing.

Chronic Medical Problems (Past Medical History [PMH])

• High blood pressure

• Ischemic stroke (1 year ago)

Family History (FH)

• Father: High blood pressure and heart attack

• Mother: Arthritis

Social History (SH)

I smoke ½ pack per day and have done so for the past 20 years.

I eat mainly TV dinners.

I do not exercise.

Prescription Medications/Indications/Adherence

• Lisinopril 40 mg by mouth daily for blood pressure and stroke

• Augmentin 875 mg by mouth twice daily for my cold

• Adherence: I take all my medication as prescribed.

Nonprescription (OTC) Medications, Herbals, Supplements, Vitamins

• Acetaminophen 650 mg by mouth every 6 hours as needed for pain

• Mucinex DM for my cough

Allergies to Medications, Foods, and Type of Reaction

Bactrim (rash)

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