Daniel DeMarco Focused H&P#1 Ambulatory Care

Chief Complaint: Cough with Mucus, Sore Throat x 5d

 

History of Present Illness:

MM is a 32yo Male presenting to office with complaint of cough with green mucus production and sore throat x 5d. Patient states that his symptoms started with a dry cough which became productive. He states that the sore throat has gotten worse. Admits nasal and chest congestion. Patients admits sick contact – nephew was sick with something similar one week ago. Has tried NyQuil with minimal relief. Denies fever, chills, nausea, vomiting, diarrhea, myalgias, arthralgias, sinus pressure, foreign travel.

 

Allergies: NKDA

Medications: Denies

PMH: Denies

PSH: Denies

Social History: Denies EtOH use, tobacco use, marijuana use, other illicit drug use.

Sexual History: Identifies as male. Has one female partner. No history of STDs.

Family History: Denies

 

Review of Systems:

General: Denies fever, chills, anorexia, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Admits congestion, sore throat. Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, ear pain

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, history of murmur, fainting, or dizziness with activity 

Respiratory: Admits productive cough. Denies wheezing, shortness of breath

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Denies HI/SI, feelings of helplessness, hopelessness

 

Physical Exam:

Vital Signs:

BP: 128/82

Pulse: 88bpm

RR: 14 breaths/min

Temp: 37.0C

SpO2: 100%RA

Ht: 70.0 inches

Wt: 77kg

 

General Survey: Alert, NAD. Appears stated age.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Head: NC/AT. Non-tender to palpation throughout. Frontal and maxillary sinuses nontender to palpation and percussion.

Eyes: PERRLA. EOM intact and nonpainful. Red reflex present bilaterally. No crusting on lashes. No discharge.

Ears: External ear with no masses, lesions. Nontender to palpation. Auditory canal with no injection. B/L TMs pearly gray with cone of light in appropriate position.

Nose: Nares patent. Mucosa pink. Septum midline. Turbinates non-boggy, non-hyperemic.

Throat: Moderate pharyngeal erythema. Good dentition. Gingiva without lesions, masses. Uvula midline. No tonsillar swelling. 

Neck: Supple. No thyromegaly. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Nondistended. BS +. Soft, non-tender. No guarding, rebound tenderness. No hepatosplenomegaly.

 

Assessment/Plan:

MM is a 32yo Male with 5d complaint of worsening productive cough, sore throat, and congestion consistent with bacterial upper respiratory tract infection.

 

#Bacterial Upper Respiratory Tract Infection

– Rapid Strep Negative

– Start Azithromycin 500mg PO on first day, then 250mg PO qd x 4d

– Start Guaifenisin 600mg PO q12h x 5d

– If severe facial pain, intractable fevers, eye pain, inability to eat or drink, go straight to ER

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student