Medication Intolerances case study

“Persistent cough for two months.”

Pneumonia, Upper airway cough syndrome, Epiglottitis, Vocal cord dysfunction, obesity or overweight, obstructive sleep apnea, rhinitis or sinusitis, Asthma.

Allergies: None.

Medication Intolerances: None.

Chronic Illnesses/Major traumas – None.

Hospitalizations/Surgeries – None 

gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea, stress, and depression. It appears that Mr. Dennison does have rhinitis or sinusitis which may aggravate his asthma

persistent cough

Denies chest pain or palpitations.

Denies bruising or rashes. Denies noted lesions.

coughing and whistling noises that you are making at night may be due to asthma.

: Normal sclerae and conjunctivae. No discharge or “allergic shiners” are present.

Denies N/V/D, ABD pain, or hemorrhoids.

Tympanic membranes are normal.

Has not had a previous mammogram. Last pap smear was 5 years ago.

Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present.: Normal appearing; no signs of postnasal drainage.

Denies joint swelling or significant back pain. Denies diagnosis of Osteoporosis.

Denies breast lumps, discharge, or pain.

Denies history of syncope or seizures.

Denies easy bruising, swollen glands, or intolerance of heat or cold. Admits to occasional hot flashes.

Denies suicidal ideation or anxiety.

Healthy appearing male, mildly overweight.

No rashes or lesions.

Unremarkable. Good dental hygiene, Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage presen. Normal thyroid without evidence of thyroid nodules. Midline trachea.

S1, S2 normal without murmurs or gallops. Pulses equal throughout.

mild scattered wheezes heard throughout

No hepatosplenomegaly, masses, or tenderness.

Symmetric in shape, free of masses and discharge.

Non-distended bladder. External genitalia without concerns.

Normal ROM throughout. Appropriate muscle development.

Cranial nerves intact throughout. Normal sensation, reflexes, and strength. Normal gait.

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

· 1- Asthma (J45.909)

· 2- Chronic sinusitis (J32.9)

· 3- Cough (R05)

· Medication for Moderate Persistent Asthma

· Antibiotic for chronic sinusitis.