Daniel DeMarco Focused H&P#5 Ambulatory Care

Chief Complaint: Right Rib Pain

 

History of Present Illness:

45yo Male presenting to office with complaint of Right Rib Pain. Patient states that he has a cough x 2months that if productive of clear mucus. Has been seen multiple times here and by PCP and treated with Prednisone, Tessalon Perles with no relief. PCP recently prescribed albuterol with some relief and gave the patient a referral to Pulmonology whom the patient will follow with on Monday. He is complaining today of intercostal rib pain. It is worse with deep breathing and coughing. Denies trauma, fever, chills, hemoptysis, weight loss, night sweats, heartburn, wheezing.

 

Allergies: NKDA

Medications: Albuterol sulfate 108mcg 2 puffs inhaled q4-6h prn, Atorvastatin 10mg 1 tablet PO qd

PMH: HLD

PSH: Denies

Social History: Former tobacco use – 20years x 1pack per day = 20pack years. Admits marijuana use – one marijuana cigarette daily. Denies EtOH use, other illicit drug use.

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

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: 126/76

Pulse: 55bpm

RR: 14 breaths/min

Temp: 37.0C

SpO2: 97%RA

Ht: 64.0 inches

Wt: 64kg

 

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: Oropharynx nonerythematous. 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: Tenderness to palpation over 8th and 9th intercostal space. Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

 

Assessment/Plan:

MF is a 45yo Male with worsening Right Rib Pain worse with deep breathing and coughing and TTP over affected area consistent with costochondritis.

 

#Costochondritis 2/2 Cough

– Start Naproxen Tablet 500mg q12h x 10d

– Follow up with Pulmonology on Monday

– Continue OTC Lidocaine Patches prn for pain

– If fever, chills, worsening shortness of breath, severe chest pain, go straight to ER

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student