Daniel DeMarco Focused H&P#9 Ambulatory Care

Chief Complaint: Cough, sore throat, sinus pressure x 1wk

 

History of Present Illness:

DM is a 35yo Female presenting to office with complaint of cough, sore throat and sinus pressure x 1wk. Cough initially dry but now productive of green sputum. Admits fever, chills, body aches for last 3d. Denies headache, eye pain, shortness of breath, nausea, vomiting, lightheadedness/dizziness. Tried dayquil with no relief. Patient states she gets sinus infections almost every 2 months which resolve when treated with antibiotics.

 

Allergies: NKDA

Medications: Metformin HCl 500mg 1 tablet PO qd

PMH: DM2

PSH: Denies

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

Family History: Denies

 

Review of Systems:

General: Admits fever, chills, myalgias. Denies anorexia, weight loss, weight gain

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

HEENT: Admits sore throat, sinus pressure. Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, congestion, 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 cough productive of green sputum. 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: Admits myalgias. Denies arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

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

 

Physical Exam:

Vital Signs:

BP: 112/80

Pulse: 94bpm

RR: 18 breaths/min

Temp: 36.8C

SpO2: 95%RA

Ht: 63.0 inches

Wt: 91kg

 

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. Maxillary > Frontal sinuses with tenderness 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: Mild 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.

 

Assessment/Plan:

DM is a 35yo Female with 1wk complaint of worsening productive cough, sinus pressure, sore throat, fever and chills and physical exam findings consistent with Acute Sinusitis.

 

#Acute Sinusitis

– Start Amoxicillin-Clavulanate Tablet 875-125mg 1 tablet orally q12h x 10d

– Start Guaifenisin 600mg PO q12h x 10d.

– OTC IBU/APAP prn for pain/fever

– PO fluid intake encouraged, regular diet

– If eye pain, pain with EOMs, intractable fevers, worsening symptoms, go straight to ER

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student