Persistent cough for two months
Name Mr. Dennison.” | Date: 08/25/2020 | Time: 1000 |
Family Medicine case 02 | Age: 40 yo | Sex: male |
SUBJECTIVE | ||
CC:
“Persistent cough for two months.”
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HPI:
Pneumonia, Upper airway cough syndrome, Epiglottitis, Vocal cord dysfunction, obesity or overweight, obstructive sleep apnea, rhinitis or sinusitis, Asthma.
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Medications: cetirizine pills and his inhaled fluticasone nasal inhaler.
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PMH
Allergies: None.
Medication Intolerances: None.
Chronic Illnesses/Major traumas – None.
Hospitalizations/Surgeries – None |
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Family History | ||
Social History
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 |
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ROS | ||
General
persistent cough
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Cardiovascular
Denies chest pain or palpitations.
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Skin
Denies bruising or rashes. Denies noted lesions.
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Respiratory
coughing and whistling noises that you are making at night may be due to asthma. |
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Eyes
: Normal sclerae and conjunctivae. No discharge or “allergic shiners” are present.
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Gastrointestinal
Denies N/V/D, ABD pain, or hemorrhoids.
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Ears
Tympanic membranes are normal. |
Genitourinary/Gynecological
Has not had a previous mammogram. Last pap smear was 5 years ago.
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Nose/Mouth/Throat
Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present.: Normal appearing; no signs of postnasal drainage.
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Musculoskeletal
Denies joint swelling or significant back pain. Denies diagnosis of Osteoporosis. |
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Breast
Denies breast lumps, discharge, or pain. |
Neurological
Denies history of syncope or seizures. |
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Heme/Lymph/Endo
Denies easy bruising, swollen glands, or intolerance of heat or cold. Admits to occasional hot flashes. |
Psychiatric
Denies suicidal ideation or anxiety. |
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OBJECTIVE | ||
Weight 190lb BMI 28.9kg/m^2 | Temp 98.2 | BP 118/68 |
Height 5’8” | Pulse 80 | Resp 16 |
General Appearance
Healthy appearing male, mildly overweight. |
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Skin .
No rashes or lesions. |
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HEENT
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. |
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Cardiovascular
S1, S2 normal without murmurs or gallops. Pulses equal throughout. |
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Respiratory
mild scattered wheezes heard throughout |
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Gastrointestinal
No hepatosplenomegaly, masses, or tenderness. |
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Breast
Symmetric in shape, free of masses and discharge. |
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Genitourinary
Non-distended bladder. External genitalia without concerns. |
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Musculoskeletal
Normal ROM throughout. Appropriate muscle development. |
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Neurological
Cranial nerves intact throughout. Normal sensation, reflexes, and strength. Normal gait. |
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Psychiatric
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. |
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Lab Tests :None | ||
Special Tests : CT scan of the maxillary sinus, it can see ethmoid sinus opacification and maxillary sinus mucosal thickening | ||
Diagnosis it can see ethmoid sinus opacification and maxillary sinus mucosal thickening.” |